VA Training and Fast Letters - Any others to add?

VA Training and Fast Letters - Any others to add?

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Nov 3 10 8:52 PM

The following is the index for the various Training and Fast Letters. These letters are not necessarily in the original formatting. I have tried to present them in an easy-to-read form instead of some forms as originally presented. Some of the paragraphs were WAAAAYYY too long. lol

Something to be aware....

Some of these letters may be rescinded, outdated, or otherwise no longer viable. I have still included them because sometimes they provide additional insight or just plain more information than the newest version.

Use them wisely.

Coding of the letters...
FL = Fast Letter
TL = Training LetterFirst two numbers = last two digits of year of origin

These letters are grouped as Training Letters, Fast Letters, Miscellaneous, and VHA Directives. The list shows newest first with the older in descending order.

I have eliminated Date of Input. Instead, I will put the word NEW at the beginning of the latest letter(s). This should make it easy to see what new Stuff I have added without having to look at the actual reply. Whenever I input new documents, the previously noted will revert to the common list.

Before beginning the lists, I will note the REPLY number of the comments others have made. This will allow viewers to find them more easily.

***********************MEMBER COMMENTS

11, 14-16 26-31, 70-74

***********************TRAINING LETTERS
NUMBER TITLE

NEW TL 11-03 REVISED Processing Disability Claims Based on Exposure to Contaminated DrinkingWater at Camp Lejeune (November 29, 2011) – REPLY #136, PAGE 7 - (NOTE: FL 11-03 is the original of this. It can be found at REPLY 108, Page 6. Am keeping the letters as they are since that is how the government wrote them.)

****
TL 10-04 REVISED NEHMER Training Guide for the readjudication of Claims for Ischemic Heart Disease (IHD), Parkinson‟s Disease (PD), Hairy Cell Leukemia (HCL) and other Chronic B-cell Leukemias, and other Diseases Under Nehmer (February 10, 2011), LINK--- http://vets.yuku.com/topic/63496 (This was too long to put in this topic, so I created its own topic and linked it. ☺ ) (Also created a REPLY topic with link within this topic, REPLY #132, Page 7 )

TL 10-04 REVISED NEHMER Training Guide for the readjudication of Claims for Ischemic Heart Disease (IHD), Parkinson‟s Disease (PD), Hairy Cell Leukemia (HCL) and other Chronic B-cell Leukemias, and other Diseases Under Nehmer (September 28, 2010), LINK---http://vets.yuku.com/topic/53535 (This was too long to put in this topic, so I created its own topic and linked it. ☺ ) (Also created a REPLY topic with link within this topic, REPLY #123, Page 7 )

FL 11-03 Consolidation and Processing of Disability Claims Based on Exposure to Contaminated Drinking Water at Camp Lejeune, North Carolina (January 11, 2011), REPLY 108, Page 6- (NOTE: TL 11-03 dated November 29, 2011 is the revised edition of this document, which can be found at REPLY #136, PAGE 7. Am keeping the letters as they are since that is how the government wrote them.)

NEW TEGL 10-09 Implementing Priority of Service for Veterans and Eligible Spouses in all qualified Job Training Programs Funded in whole or in part by the U.S. Department of Labor (DOL) – U.S. Department of Labor – (November 10, 2009) - REPLY #137, PAGE 7

1. Enclosed is training material that includes both medical information and some rating guidelines on diabetes mellitus and its complications. This letter is not intended to make policy but to restate and clarify existing policy.

What is diabetes mellitus (DM)?
Diabetes mellitus is a metabolic disorder in which the body is unable to use glucose (a type of sugar obtained from food) effectively. Hyperglycemia, an abnormally high level of blood sugar, results.

What does the pancreas have to do with diabetes?
Glucose is the main source of fuel for the body for energy and growth. There is a narrow range of blood glucose that is optimal—70 mg/dl to 110 mg/dl. Insulin and glucagon are hormones produced by the pancreas that regulate the level of blood glucose. Most of the pancreatic tissue produces enzymes that aid in digestion, but about 5% produces hormones instead. Insulin is produced in the pancreas by specialized cells called beta cells in the islets of Langerhans or pancreatic islets (groups of cells scattered throughout the pancreas), and glucagon is produced by alpha cells in the islets of Langerhans.

What is the action of insulin and glucagon?
After eating sugar or starch, the blood glucose level rises. This high blood glucose is the signal for the pancreas to release insulin, which then lowers the blood glucose by moving it out of the blood into cells. The blood glucose then falls to normal. Insulin helps convert glucose to glycogen, which is stored in the liver and muscles and released when glucose is needed, for example, during exercise. As the blood glucose falls, the amount of insulin secreted by the pancreas goes down.

Glucagon is produced in the opposite situation from insulin. When the blood glucose rises, no glucagon is secreted by the pancreas, but when blood glucose is low, glucagon is released. Glucagon makes the liver release stored glucose so that the blood glucose rises. Then the amount of glucagon secreted falls.

When does diabetes mellitus develop?
Diabetes mellitus arises in 2 situations that make the blood glucose rise and finally spill into the urine and make the cells of the body become starved for energy.
when the pancreas produces an inadequate amount of insulin
when the body cells do not respond effectively to the insulin that is produced in normal amounts.

What is diabetes insipidus?
Diabetes insipidus is a condition with a name similar to diabetes mellitus, but it is unrelated. It is due to a pituitary gland disorder and is characterized by extreme thirst and the excretion of large amounts of very dilute urine.
The urine is “insipid” or tasteless, in comparison with the sweet, sugar-filled urine of diabetes mellitus (mellitus = sweet as honey).

When the term "diabetes" alone is used, it refers to diabetes mellitus.

How common is diabetes?
In the U.S., 16 million people have diabetes mellitus, and about half of those do not know they have it. About 160,000 Americans die from diabetes each year.

There is variation in the incidence of diabetes among different ethnic groups. About 5-6% of whites have diabetes; 12-15% of African-Americans have it; 20% of Hispanics have it; and 35% (and up to 65% in some tribes) of Native Americans have it. The disease is very rare in undeveloped countries.

What causes diabetes?
The causes of diabetes are not known. Insulin-dependent diabetes may be more than one disease and may have many causes—hereditary factors, viruses, etc. Noninsulin-dependent diabetes is associated with obesity and with the development of resistance of the body to the action of insulin.

Risk factors for diabetes are:
a family history of diabetes.
sedentary lifestyle
central (truncal) obesity
being a member of a high-risk ethnic population
having delivered a baby > 9 lb. or having had gestational diabetes
age >45.

What are the different types of diabetes mellitus (DM)?
There are 3 common types of diabetes:
1. Type 1 (or type I) diabetes mellitus, formerly called juvenile or brittle or insulin-dependent diabetes (IDDM).
2. Type 2 (or Type II) diabetes mellitus, formerly called noninsulin-dependent or adult-onset diabetes (NIDDM).
3. Gestational diabetes mellitus (GDM).
Type I
An autoimmune disorder - the immune system body attacks and destroys beta cells in the pancreas, so the pancreas makes too little or no insulin.
Usually appears suddenly.
Most common under age 30 and more common in whites than in nonwhites.
Treatment is daily insulin, a planned diet, and regular exercise.

Type 2
Makes up 90 to 95% of diabetes.
The pancreas makes some insulin, sometimes too much, but it is not effective because the cells are resistant to insulin.
Usually gradual in onset.
Occurs most often over age 40-45 and is commonly associated with obesity, especially central obesity.
The treatment is diet, exercise, oral medication, and sometimes insulin.

Gestational diabetes (GDM)
Occurs during pregnancy and usually disappears when the pregnancy ends.
A woman who has had gestational diabetes is at increased risk for later developing Type 2 diabetes.

Other types may occur:
Diabetes may result from many other causes, such as other endocrine diseases, drugs, infections, genetic syndromes, etc.

How is diabetes diagnosed?
In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus named 3 ways to diagnose diabetes:
1. Symptoms of diabetes (such as polyuria, polydipsia, and unexplained weight loss) plus casual plasma glucose greater than 200 mg/dL (11.1 mmol/L). Casual means any time of day, without regard to meals.
2. Fasting plasma glucose (FPG) greater than 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
3. Glucose greater than 200 mg/dL (11.1 mmol/L) after a 75-g glucose load. This is not recommended for routine clinical use.
* Any of these is sufficient for diagnosis but should be confirmed by repeat testing on a separate day.

What is impaired glucose tolerance?
Impaired glucose tolerance (IGT) is a category that refers to those with fasting plasma glucose greater than 110 but less than 126. This group is at increased risk for diabetes.

What are the signs and symptoms of early diabetes?
• Type I DM usually presents with symptomatic hyperglycemia or diabetic ketoacidosis (DKA).

• Type II DM frequently is diagnosed on a routine medical examination, but may present with symptomatic hyperglycemia or hyperglycemic hyperosmolar nonketotic coma (NKHHC). Some patients are not diagnosed until they are found to have a late complication of diabetes.

What is hemoglobin A1c?
Hemoglobin A1c (HbA1C) is the part of red blood cells that carries oxygen to the cells and that also binds to glucose. It is also known as glycosylated hemoglobin (GHb). The higher the level of blood sugar, the more sugar attaches to red blood cells and therefore the higher the level of HbA1c.

The hemoglobin A1C test measures the percentage of HbA1C that is linked to glucose. The glucose stays joined to the cell for the duration of the cell’s life (about 4 months), so the test can help track the average blood glucose levels over the past 60-90 days and monitor the effectiveness of treatment.

6% is considered normal. The goal of treatment is a level of less than 7%, the level that has been shown to have fewer complications than with a level of 8% or higher. Levels of 9-12% may be seen in diabetics. Levels greater than 8% may indicate a change in treatment is needed.

What are the acute complications of diabetes?
Acute complications of diabetes include both hyperglycemia and hypoglycemia.
Hyperglycemic diabetic emergencies include diabetic ketoacidosis (DKA) and hyperosmolic non-ketotic coma (NKHHC).

What is nonketotic hyperosmolar hyperglycemic coma (NKHHC)?
NKHHC is a serious complication of Type 2 DM resulting from very high blood glucose (600-2400 mg/dL) with dehydration. It often follows an infection, stroke, myocardial infarction, or surgery, often when there is some problem that interferes with adequate oral hydration (fluid intake by mouth). Sometimes it is due to medications.

In one-third of patients, it is the first indication of diabetes. It is often seen in elderly nursing home residents and may be associated with renal insufficiency, congestive heart failure, or recent discontinuation of insulin or oral hypoglycemic agents.

The mortality rate may be up to 50%. Symptoms include polyuria, polydipsia, evidence of severe dehydration, nausea, weakness, lethargy, tachycardia, hypotension, vision problems, confusion, delirium, convulsions, seizures, and ultimately coma (in about 10%). These symptoms may develop over a period of days or weeks.

What is diabetic ketoacidosis (DKA)?
DKA develops gradually when the blood glucose level rises and there is insufficient insulin to deal with it. This may happen because of stress, acute illness, eating too much, not taking enough insulin, etc. It is much more common in Type 1 DM.

The lack of insulin results in starvation of the body’s cells, so they lack energy and start to break down fat for fuel. This results in the production of ketones in the blood, a condition called ketoacidosis. This may result in coma if not treated rapidly.

Treatment often requires hospitalization and includes fluid and electrolyte replacement and insulin. The mortality rate of DKA is less than 5%.

What is hypoglycemia?
Hypoglycemia is too low blood glucose (below 70). It is the most common complication of the treatment of diabetes. It may occur because of eating too little food after taking diabetes medications, excessive exercise, alcohol intake, or medication. It is more common in those on insulin.

When the blood sugar is 60 or below, it affects the brain, leading to weakness, nervousness, shaking, hunger, drowsiness, sweating, tachycardia, headache, confusion, irritability etc., and finally to seizures or loss of consciousness (insulin shock).

The treatment of hypoglycemia is immediate intake of a source of glucose such as fruit juice, sugar, non-diet soda, or glucose tablets.

What are the chronic complications of diabetes?
The chronic complications of diabetes can affect many different parts of the body—eyes, heart, feet, nervous system, kidneys. On average, complications become evident about 15-20 years after the diagnosis of DM. However, some people never develop complications, and others develop them much earlier, and even have them at the time of diagnosis. About 40% develop complications at some time.

What is diabetic nephropathy?
Diabetic nephropathy is deterioration of the kidneys due to diabetes. It occurs in 30-50% of insulin-dependent diabetics and 10-15% of non insulin-dependent diabetics. There is often a clinical syndrome of albuminuria, hypertension, background retinopathy, and a history of diabetes for more than 10 years.

What is the typical course of diabetic nephropathy?
Diabetic nephropathy is often divided into 5 stages:
I. Silent stage. Diabetic nephropathy may be silent for 10-15 years, although it is damaging the nephrons of the kidney during that time.

II. Microalbuminuria. Persistent proteinuria (protein in the urine), specifically albuminuria (albumin, a type of protein, in the urine), in the range of 30-300 mg/24 h, which is known as microalbuminuria, is the earliest stage of diabetic nephropathy. These trace amounts of albumin leak through the damaged filtering structures of the kidneys. These patients will likely progress to clinical albuminuria.

Normal albumin excretion is 15 to 30 mg/day. Detecting microalbuminuria requires a special test. It is not found on a routine urinalysis because more than 550 mg/day must be excreted for it to show up on routine testing, which is the level called macroalbuminuria or macroproteinuria. Untreated hypertension accelerates renal disease, and increased hypertension occurs in patients with microalbuminuria.

III. Clinical albuminuria or proteinuria. Clinical diabetic nephropathy is said to be present when a patient who has had diabetes for more than five years and has evidence of diabetic retinopathy develops clinically apparent albuminuria (>300 mg per 24 hours) and has no evidence of any other cause of kidney disease. The level can be as much as 2000-4000 mg/day. When albuminuria develops, there is a high likelihood of developing end-stage renal disease within 3 to 20 years.

IV. Renal insufficiency (decreased renal function) - indicated by a rising blood creatinine. About 4 years after the onset of clinical diabetic nephropathy, the serum creatinine level rises to 2 mg/dL or greater. Within an additional 3 years, about half of patients will have developed ESRD.

V. End stage renal disease (ESRD) - usually when creatinine level reaches between 3 and 8. Likely to need kidney transplantation or hemodialysis.

What are some tests for renal disease?
• creatinine - a waste product from the normal breakdown of muscle. It builds up in the blood when the kidneys are damaged and unable to remove it from blood and excrete it. Normal levels vary, but a common normal range is 0.6 to 1.2 mg/dl. One estimate of renal function is that a creatinine level of 2.0 mg/dl means there is only 50% of normal renal function remaining and 4.0 mg/dl means 25% of normal function remains.
• creatinine clearance test - indicates how fast creatinine is removed from the blood. The normal creatinine clearance rate in men is 97 to 137 ml/min. and in women is 88 to 128 ml/min.
• blood urea nitrogen (BUN) - a waste product of protein that builds up in the blood when the kidneys are damaged and unable to remove it from the blood. Normal is 7 to 20 mg./dL. of blood. It is less specific for renal disease than creatinine because it can be elevated in dehydration and heart failure.
• proteinuria - protein in the urine that occurs when damaged kidneys fail to separate the protein from the waste products.
• renal imaging - ultrasound, computed tomography (CAT scan), and magnetic resonance imaging (MRI), mainly to find tumors or urinary tract obstruction.
• renal biopsy.
• renal angiogram - when renal hypertension is suspected.

What is the treatment of diabetic nephropathy?:
Albuminuria and renal disease may be prevented or delayed by the use of ACE inhibitors, providing tight glucose control, treating hypertension, low protein diet, and control of blood lipids, but treatment will not reverse renal disease.

Hemodialysis or kidney transplant may be needed in late stages. Patients with diabetes tend to start dialysis earlier (at a lower creatinine level) than others because they develop symptoms sooner than non-diabetics.

What are the cardiovascular complications?
Atherosclerosis occurs earlier and is more severe than in the general population, but the reason is unknown. Problems may develop in the legs, with peripheral arterial disease with intermittent claudication, ulcers that don’t heal, sometimes progressing to gangrene; heart, with coronary artery disease, cardiomyopathy, or congestive heart failure; and brain, with cerebrovascular accident (stroke).

Arteriosclerotic heart disease: Coronary artery disease is the major cause of death in diabetics. Angina and myocardial infarction may be silent until they result in unexpected left heart failure. (88% of asymptomatic diabetics undergoing coronary angiography as part of screening before kidney transplant had significant coronary disease.) Another cardiac complication is cardiomyopathy without coronary artery disease.

Diabetics have the same risk factors for arteriosclerotic heart disease as the general population—smoking, hypertension, elevated blood lipids, obesity—but diabetes greatly increases the risk. The risk of death following a myocardial infarction is 40-50% in diabetics, and 25 to 30% in non-diabetics. Unlike other complications, good blood glucose control will not prevent the development of heart disease.

Half of all diabetics have hypertension, but it is not ordinarily due to the diabetes—except when it results from diabetic nephropathy.

What is diabetic neuropathy?
Diabetic neuropathy is a group of disturbances that occur frequently in diabetics that can affect many parts of the nervous system. The peripheral nerves go out from the brain and spinal cord to muscles, skin, and internal organs. Peripheral neuropathy may be asymptomatic until a serious complication, such as foot ulcer or cardiac arrhythmia, develops.

The cause of diabetic neuropathy is not known, but may be due to a disturbance of nerve metabolism or ischemia (inadequate blood supply) of the nerves. Risk factors that contribute are increasing age, male sex, increasing height, long duration of diabetes, poor glucose control, hypertension, alcohol consumption, and smoking.

Examinations for diabetic neuropathy assess muscle strength, deep tendon reflexes, and sense of touch (temperature, pinprick or pressure sensation, vibratory sensation, position sense). Different functions are affected in different individuals, and symptoms may be out of proportion to the findings on examination. Diagnostic criteria are based on some combination of symptoms, focused neurologic examination, nerve conduction studies, and special quantitative sensory tests, but some tests are difficult and time consuming, and not all are ordinarily done.

There are several different classifications of diabetic neuropathy. One groups it into 3 categories:
• Distal symmetrical polyneuropathy.
• Focal neuropathy.
• Autonomic neuropathy.

Distal symmetric polyneuropathy
This is the most common type of diabetic neuropathy. It is primarily sensory. It can affect the feet, legs, hands, and arms. It is characterized by peripheral neuropathy that is usually bilateral and symmetrical. It typically begins insidiously in the toes and progresses up the legs. It then affects the fingertips and later the chest and abdomen. It always starts distally and moves proximally.

About 12% of diabetics have it at the time of diagnosis of diabetes, and almost 60% have it after 25 years of diabetes.

Symptoms vary, but may include
paresthesias - numbness and tingling
hyperesthesias - increased sensitivity—to touch, etc.
hypesthesia (or hypoesthesia) - decreased sensitivity—to touch, etc.
loss of sensation
pain - often burning, may be lancinating or lightning, may be severe
and debilitating, often worse at night
dysesthesia - unusual and unpleasant sensation, sometimes extremely
painful, after normal stimulation
muscle weakness.
The findings are typically in a stocking-glove distribution. Ankle jerks are usually decreased or absent. The same patient may show both pain and insensitivity to pain.

Complications include:
abnormalities of gait (sensory ataxia - loss of balance and poor
muscle coordination due to loss of position sense)
Charcot joints (neuropathic osteo-arthropathy), which includes
degenerative changes, instability, and possibly fragmentation of
bones, particularly in the joints of the feet and ankle.
neuropathic ulcers of the feet. May lead to gangrene and amputation.
injuries and burns - may be unnoticed and become infected.

Mononeuropathy (focal)
Mononeuropathy is less common than polyneuropathy. It involves isolated neuropathy of a single nerve, often with paralysis of the 3rd ,4th, or 6th cranial nerve (eye muscle nerves), with the 3rd being most common, or the 7th cranial nerve, on one side. It can also affect peripheral nerves, causing a sudden wrist or foot drop. Compression neuropathies, such as carpal tunnel syndrome, may also occur. Mononeuropathy may improve spontaneously after weeks to months and is believed to be due to nerve infarction.

Radiculopathy (focal)
Neuropathy of a spinal nerve root may occur, producing pain over the distribution of one or more spinal nerves, usually on the chest wall or abdomen. It also causes sensory loss. Like mononeuropathy, the lesion is usually self-limited.

Autonomic neuropathy
The autonomic nervous system includes sympathetic and parasympathetic nerves that supply heart muscle, smooth muscle (such as the muscle lining walls of arteries and the digestive tract), and glands, all organs that work without our conscious control. Neuropathy of the autonomic nervous system can have broad effects on the cardiovascular, digestive, and genitourinary systems, and on the sweat glands.

Cardiovascular autonomic neuropathy: Among the effects are decreased cardiac sensation so that angina or the pain of myocardial infarction goes unnoticed until congestive heart failure develops.

Another potential cardiovascular problem is orthostatic (postural) hypotension (low blood pressure) with syncope (fainting). Cardiorespiratory arrest and sudden death have been reported.

Urinary tract autonomic neuropathy: Can cause incomplete bladder emptying, with stasis of the urine predisposing to infection of the bladder and kidneys. Incontinence is possible because of decreased sensation or difficulty controlling urination. Chronic catheterization may be necessary.

Delayed gastric emptying (sometimes with a dumping syndrome) may occur due to vagus nerve involvement. When severe, it is called gastroparesis (literally, paralysis of the stomach). It may cause nausea, vomiting, early satiety (feeling of fullness in the stomach), bloating, abdominal pain, weight loss. If longstanding, bezoars (masses of hardened food) may develop and obstruct the stomach. It is treated by diabetes treatment, drugs, and at times a feeding tube or parenteral nutrition.

Sweat gland autonomic neuropathy: May cause problems with regulation of body temperature or excess sweating (often at night or during meals).

Sexual dysfunction includes impotence and retrograde ejaculation, usually irreversible. Impotence occurs in 50 to 60% of men with diabetes. It is believed to be due to nerve damage and decreased circulation, but may stem from medications used to treat DM.

What are the foot complications?
Diabetics are at risk for foot problems if they have distal symmetrical polyneuropathy and/or peripheral vascular disease with poor circulation. There are 42 muscles, 26 bones and 29 joints in the foot that may be damaged due to diabetes.

Ulcers are a common foot problem. They may be due to abnormal pressure resulting from neuropathy or poor fitting shoes, combined with a lack of sensitivity to pain. They may be preceded by a callus. Injuries of which the patient is unaware are common. Osteomyelitis and gangrene may follow.

Amputations are 15 times more common in people with diabetes than in those without it. Peripheral neuropathy, peripheral vascular disease, and infection are all contributory causes. Amputation of one lower extremity predisposes to amputation of the other because of increased stress on the opposite leg, resulting in ulcers, infection, etc.

What are the skin complications?
In addition to infections (for example, Candida, dermatophytes, and bacterial infections) and ulcers, there are several specific conditions that may affect diabetics.

• Necrobiosis lipoidica diabeticorum - plaque-like yellow to brown lesions over the anterior tibial surfaces of the legs that may ulcerate. It develops over months and may last years. The cause is unknown.
• Diabetic dermopathy ("shin spots") - small plaques with a raised border, also usually over the anterior tibial surfaces that may also ulcerate. Cause is unknown.
• Bullosis diabeticorum - blisters spontaneously appearing on the hands or feet that heal in 2-5 weeks, sometimes with scarring and atrophy.
• At the site of insulin injections, fatty tissue may atrophy, or the skin may thicken with an accumulation of fat resembling a lipoma.

What are the eye complications?
The most common eye problems in diabetics are:
Diabetic retinopathy - impairment or loss of vision due to damage to the blood vessels of the retina.
Cataract--clouding or opaqueness of the lens of the eye.
Glaucoma--increased fluid pressure in the eye. Causes loss of visual fields due to optic nerve damage.

How common are diabetic eye complications?
Diabetes is the leading cause of adult blindness. About 2% of people with Type 2 DM suffer total loss of vision.

Who is likely to get diabetic eye complications?
Anyone with diabetes may get eye complications, but they are more likely the longer someone has had diabetes. Almost half of diabetics will develop diabetic retinopathy during their lifetime.

Two early warning signs of retinopathy are microalbuminuria and decreased dark adaptation. Diabetic eye disease is associated with poor control of blood glucose and blood pressure.

What causes eye damage?
This is largely due to blood vessel damage from high blood sugars:
Leakage (hemorrhage): from damage to capillaries.
Blood vessel blockage: partial or total, decreases blood supply.

What is the retina?
The retina is a very thin light-sensitive tissue at the back of the eye. When light enters the eye, the retina changes the light into nerve signals and sends them along the optic nerve to the brain to make vision possible.

What are the types of retinopathy?
The 2 main types of retinopathy are:
background, or simple retinopathy (BDR)
proliferative retinopathy
preproliferative retinopathy is sometimes listed as a 3rd type

What is the course of retinopathy?
Retinopathy affects the small blood vessels of the eye. It begins as background retinopathy (BDR), which is an early stage of damage that can be diagnosed before vision is impaired by an examination of the eyegrounds by ophthalmoscopic examination. The characteristics of background retinopathy are:
• Microaneurysms - the earliest visible changes, due to weakened blood vessel walls causing the vessels to bulge. They look like scattered red spots in the retina. They may leak blood (hemorrhages) or fluid (exudates) into the surrounding tissue.
• Hemorrhages - bleeding into the retinal layers from damaged blood vessels. Only a problem when bleeding occurs in or near the macula.
• Hard Exudates - proteins and lipids also leak out of the blood into the retina through damaged blood vessels. They look like hard white or yellow areas around leaking capillaries. Only a problem if the macula is involved.

About 80% of people who have had diabetes for over 20 years have some background diabetic retinopathy, but 75-80% of those never develop serious vision problems. However, BDR can progress to macular edema or proliferative retinopathy.

Macular edema can occur if the microaneurysms, hemorrhage, and exudates of BDR occur within the macula, which is the central 5% of the retina most critical to vision. Macular edema may lead to blurred vision, and there may be progressive visual loss and inability to focus clearly. This may occur at any stage of retinopathy.

Some call the following changes preproliferative diabetic retinopathy:
• Intraretinal Microvascular Abnormalities (IRMA): - irregularly-dilated blood vessels in a localized area of the retina.
• Cotton Wool Spots: - white areas in the retina where blood vessels are blocked, and localized areas of nerves have been damaged.

Proliferative retinopathy: occurs when small, fragile, abnormal new blood vessels develop and grow out of control across the eye. This is called neovascularization. It may be associated with retinal detachment or hemorrhage, which can cause blindness.

The new vessels grow out into the vitreous gel (the clear jelly-like substance that fills the middle of the eyeball) and are very prone to bleeding, especially with a sudden motion or rise in blood pressure. Until they bleed, someone is unlikely to know they have eye problems. Hemorrhage can cause blurred vision or temporary blindness.

If extensive or repeated bleeding occurs, fibrous tissue or scarring can form near the retina. Since the retina is so thin, being made up of only a few layers of cells, scarring can pull or detach the retina away from the back of the eye. Retinal detachment may be noted as wavy lines or a curtain-like effect that appears in one area of vision. It may result in permanent visual impairment.

How is proliferative diabetic retinopathy treated?
• Laser surgery can reduce the risk of visual loss from proliferative diabetic retinopathy by 60%. It is used to seal or shrink the abnormal blood vessels. Can also reduce visual loss from macular edema by 50%.
• Vitrectomy surgery (removal of the clear vitreous gel in the eye and replacement with a salt solution) may restore useful vision when retinopathy is too advanced for laser surgery—e.g., those who have vitreous hemorrhage or scarring with retinal detachment.

How common are cataracts in diabetics?
Diabetics are twice as likely to get a cataract as a person who does not have the disease, and they develop at an earlier age in people with diabetes.

What are the types of cataracts that diabetics get?
Senile cataract - the most common type. Almost exclusively in those > age 60. The underlying damage begins decades earlier. Diabetes raises the risk about 40%.

Vitrectomy - In one study, 63% of eyes that had had a vitrectomy developed cataracts compared to only 4% in the non-vitrectomised eye.

Sugar cataract - mostly young adults with poor control of Type I DM. Can grow rapidly with complete loss of vision in as little as 3 days.

How common is open-angle glaucoma in diabetics?
Open-angle glaucoma is 1.4 to 2 times more common in the diabetic population. The older a person is and the longer a person has had diabetes, the greater the risk of glaucoma. It results from high fluid pressure within the eye. As the pressure increases, it can compress the optic nerve and the blood vessels that nourish the retina and cause a slow loss of peripheral vision and eventual blindness.

Treatment may include medications, laser, or other forms of surgery.

What are some miscellaneous complications?
Vaginal and oral thrush or moniliasis - may be troublesome during periods of high blood glucose and urine spillage of glucose.

Other infections
Hyperglycemia causes the white blood cells of the immune system to function poorly. In addition, all of the body's fluids have higher levels of sugar and nutrients, which make them more inviting for bacteria to grow and multiply. Therefore, with poorly controlled diabetes, there is a higher risk of infection, and often the infections are more serious and harder to cure. Urinary tract and vaginal infections are particularly common.

Four unusual infections appear to have a specific relationship with diabetes.
• Malignant external otitis, a bacterial infection in older patients that causes severe ear pain, necrosis of the external auditory canal, fever, and sometimes paralysis of the facial nerve. Other cranial nerves may be involved, and there may be osteomyelitis of the base of the skull.
• Nasopharyngeal mucormycosis, a rare and serious fungal infection that usually develops during or following an episode of diabetic ketoacidosis. Has sudden onset with periorbital edema, pain, bloody nasal discharge, and increased lacrimation (tearing). The nasal mucosa and underlying tissues become black and necrotic. Can extend into the orbit or base of the skull. Serious neurologic complications may occur. If untreated, death usually occurs in a week to 10 days.
• Emphysematous cholecystitis begins as an attack of biliary colic which rapidly progresses. Probably due to small vessel ischemic disease. Recognized by X-rays that show gas in or around the gall bladder. Gangrene of the gallbladder is 30 times more frequent than in the usual cholecystitis.
• Emphysematous pyelonephritis is also recognized on X-rays by seeing gas in the kidney area. Antibiotic therapy is usually ineffective, and nephrectomy may be required. Mortality rates of 80% have been reported.

Pregnancy Complications of DM
• Gestational diabetes occurs in 4% of women. They have an increased risk of developing diabetes later in life.
• Twice as likely to have a large baby than women without diabetes.
• Cesarean sections are three to four times more likely.

Can complications be prevented?
A large 10-year clinical study (The Diabetes Control and Complications Trial (DCCT)) assessed the effects of intensive therapy on the long-term complications of diabetes. It showed that strict control of blood sugar by intensive management slowed the onset and progression of eye, kidney, and nerve diseases caused by diabetes. Specifically, it showed:
• 76% reduced risk of retinopathy
• 50% reduced risk of clinical nephropathy
• 60% reduced risk of neuropathy

The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia.

These results do not necessarily apply to type 2 diabetics. In fact, concern has been raised that insulin treatment in type 2 patients may accelerate macrovascular disease.

What role does insulin have in diabetes management?
The pancreas of type 1 DM patients makes no insulin or insufficient insulin, so daily injections of insulin, usually multiple, are necessary. The exact types, amounts, and timing of the insulin injections are individually determined, and food intake must be matched to this.

Some people with type 1 DM require an insulin pump for adequate glucose control. It delivers small amounts of insulin throughout the day, through a needle, usually inserted in the abdominal wall. The amount is tailored to the individual’s activities and mealtimes and requires close monitoring of blood glucose. Brittle diabetics are type I DM patients who exhibit frequent, rapid swings in glucose levels without apparent cause.

Patients with type 2 DM may also need insulin if they do not respond well to diet, exercise, and oral medications.

The duration of insulin is another way it is classified. There are short-acting (rapid-acting), intermediate-acting, and long-acting types, based on the rate of insulin absorption from the injection site.
Rapid-acting insulins
Regular insulin, the only insulin preparation that can be given IV, works for two to four hours.
Lispro insulin works for about 2 hours.
Semilente insulin is a slightly slower rapid-acting insulin.
Intermediate-acting insulin
NPH (neutral protamine Hagedorn).
Lente.
Long-acting
PZI (protamine zinc insulin).
Ultralente.

Mixtures of insulin preparations with different onsets and durations of action are frequently given in a single injection.

In the DCCT study, type I DM patients received an average total dose of about 40 U insulin a day. Type II DM patients are insulin resistant and may require much more insulin. The dose is adjusted to maintain preprandial (before a meal) plasma glucose between 80 and 150 mg/dL (4.44 and 8.33 mmol/L).

What are the most frequent complications of insulin treatment?
• Hypoglycemia is the major complication. It may occur because of an error in insulin dosage, taking in too little food or missing a meal, excessive alcohol, or unplanned exercise. Sometimes it occurs without apparent cause.
• Weight gain. Obesity itself is an insulin-resistant state that contributes to a cycle of worsening insulin resistance, increasing insulin requirements, and further weight gain.
• Generalized insulin allergy can occur when treatment is discontinued and restarted after a lapse of months or years. Symptoms may include urticaria, angioedema, pruritus, bronchospasm, and, in some cases, circulatory collapse.
• Insulin resistance is an insulin requirement of 200 U/day or more.
• Local fat atrophy or hypertrophy at injection sites.

What role does diet play in treatment?
All insulin-treated patients require detailed diet management, including a prescription for their total daily caloric intake; guidelines for proportions of carbohydrate, fat, and protein in their diets; and instruction on distributing calories among individual meals and snacks.

What role do oral medications have in type 2 DM?
If improvement in hyperglycemia is not achieved by a diet to achieve weight reduction in type II DM patients, a drug (an oral hypoglycemic agent) will be used.

Oral hypoglycemic agents are not useful in type I DM patients. They are unable to prevent symptomatic hyperglycemia or DKA in such patients.

The following categories of drugs are now available:
• Sulfonylureas - action is to stimulate the pancreatic beta cells to produce more insulin.
• Biguanides - action is to slow the ability of the liver to produce and release too much glucose.
• Glucoside inhibitors - action is to slow the digestion of some carbohydrates (starches).
• Thiazolidinediones - action is to make the muscle cells more sensitive to insulin.
• Meglitinides - action is to stimulate the pancreas to produce more insulin.

Side effects/complications of glucoside inhibitors:
Gas, bloating, and diarrhea - often transient

Meglitinides
Repaglinide (prandin) - approved 1997.

Side effects/complications of meglitinides
hypoglycemia
weight gain

Thiazolidinediones
Pioglitazone (Actos) - approved 1999.
Rosaglitazone (Avendia) - approved 1999.
Troglitazone (Rezulin) - approved 1997, withdrawn 2000.
In March 2000, the U.S. Food and Drug Administration ordered an immediate recall of troglitazone (Rezulin) after it was linked to 28 deaths and cases of liver failure. It has been withdrawn from the market.

What are the benefits of treatment?
• Decreased risk of DKA or NKHHC.
• Less blurred vision and less risk of polyuria, polydipsia, fatigue, weight loss, vaginitis, etc.
• Greatly decreased risk of development or progression of diabetic retinopathy, nephropathy, and neuropathy.
• Improvement in blood lipids.

How is diabetes rated?
10% requires 1 criterion
diet.
20% requires 2 criteria
oral drugs and diet or
insulin and diet.
40% requires 3 criteria
insulin
diet
regulation of activity.
60% requires 5 criteria, one of which provides alternatives
insulin
diet
regulation of activity
(a) episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or (b) twice a month visits to a diabetic care provider
complications that would not be compensable if separately evaluated.
100% requires 5 criteria, 2 of which provide alternatives
more than one daily injection of insulin
restricted diet
regulation of activities
(a) episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or (b) weekly visits to a diabetic care provider
(a) progressive loss of weight and strength or (b) complications that would be compensable if separately evaluated.

Why are frequency of hospitalizations and visits to a diabetic care provider part of the evaluation criteria?
Frequency of health care visits and contacts and hospitalizations are used as criteria because they are an indicator of diabetic control and the severity of complications.
∗ Some patients require hospitalization for initiation or change of therapy.
∗ When starting insulin treatment or having a major change in insulin program, a patient may need to be in contact with their health care providers as often as daily.
∗ Patients beginning treatment with oral drugs may need to be in contact as often as weekly.
∗ Frequent contact may be required if undergoing intensive insulin therapy, are not meeting blood glucose or blood pressure goals, or have evidence of progressive microvascular or macrovascular complications.

What is different about examinations for DM?
Examinations for diabetes are generally more complex and time consuming than the average examination. Sometimes a complication is overlooked or fails to be reported by an examiner in the flood of medical findings.

In some cases, several medical specialty exams may be called for, although a general medical exam should be sufficient in most cases, except for vision and hearing problems, or unusually complex situations.

Failure of a rater, for whatever reason, to address all of the existing complications of diabetes is one of the common rating errors.

How are complications rated?
Complications of compensable degree are rated separately unless used to support a 100% evaluation. Therefore, many diabetic ratings will have to be evaluated under the eye, cardiovascular, genitourinary, musculoskeletal, neurologic, and other systems.

Diabetic eye diseases are rated as glaucoma, cataract, or retinopathy based on visual acuity, visual field loss, or diplopia, depending on the specific findings.

There is a wide range of possible ratings for diabetic nephropathy. It will be rated as renal dysfunction if renal function is affected, but as voiding dysfunction if there is incontinence from autonomic nephropathy. If chronic pyelonephritis is the problem, rating as urinary tract infection may be appropriate. Many may need to be rated as kidney transplant, hemodialysis, or nephrectomy.

Diabetic neuropathy has an even broader range of possible ratings. The effects may not be limited to paresthesias of the extremities that could be rated under 8521, for example, but may involve virtually any body system, since the entire nervous system except the brain may be involved. Therefore, there may be findings of the digestive system, cardiovascular system, genitourinary system, musculoskeletal system, etc., that need rating. Neuropathic joints, for example, may be rated as fracture or arthritis or instability.

Residuals of infections are another source of potentially great variation in rating. They range from osteomyelitis to stroke and cranial nerve paralysis, hearing loss, destruction of sinuses, foot ulcers, or gangrenous gall bladder.

On top of all this, there is the bilateral factor, the amputation rule, pyramiding, unemployability, and SMC to consider, since seldom is there a single issue to consider in diabetics once complications begin.

It’s safe to say that if you can rate diabetes well, you can rate almost anything well!

1. Enclosed is training material that includes both medical information and some rating guidelines on cardiovascular disabilities. This letter is not intended to make policy but to restate and clarify existing policy.

The cardiovascular system consists of the heart and blood vessels. The blood vessels are hollow tubes that transport blood throughout the body. The system is responsible for getting oxygenated (oxygen-containing) blood to every cell in the body and for returning the oxygen-depleted (or partially oxygenated) blood to the heart.

What are the 3 types of blood vessels?
Arteries, veins, and capillaries are the 3 types of blood vessels.
1. arteries carry blood away from the heart.
a) Are much thicker than veins and have more elastic walls.
b) The pulse is a measurement of heart rate felt as a contraction of artery in wrist.
c) Blood pressure is commonly measured at the brachial artery of the arm by means of a blood pressure cuff (sphygmomanometer) and stethoscope.
d) The higher or systolic pressure is a measurement of the force of the blood on the artery walls as the heart ventricles contract. The lower or diastolic pressure is a measurement of the force when the ventricles relax. For BP of 120/70, 120 = systolic pressure, 70 = diastolic pressure. The elasticity of arteries prevents the blood pressure from dropping to zero between heart contractions.
e) There are large, medium, and small arteries and even smaller arteries called arterioles.

The aorta is the largest artery in the body. It has 4 subdivisions:
• ascending aorta (which gives rise to the left and right coronary arteries).
• aortic arch (which gives rise to the large arterial trunks that supply the head and arms).
• descending or thoracic aorta (which supplies the lungs).
• abdominal aorta (which supplies the abdominal and pelvic organs and the legs).

2. veins - thin-walled vessels that carry blood toward the heart. Vein walls have few elastic fibers but do have valves that help keep the blood from pooling in the legs due to gravity. When the valves break down, varicose veins develop, and clots may form because the blood stagnates in the legs. Small veins are called venules. The blood pressure in the veins is much lower than that in the arteries.

3. capillaries - very thin and fragile web-like microscopic vessels that connect arteries to veins. Bruises are usually due to ruptured capillaries. Capillaries are so thin that red blood cells must move through them in single file.

What is the structure of the heart?
The heart is a hollow organ made almost entirely of muscle. The average adult heart is the size of a clenched fist (12cm.x 24cm.), with 2/3 lying in the left side of the chest. It weighs about 310 grams (11 ounces). It lies in the mediastinum, a space between the lungs that contains the heart, major blood vessels, bronchi, and part of the digestive tract. There are 4 hollow chambers of the heart:
left atrium (or left auricle)
left ventricle
right atrium (or right auricle)
right ventricle.
The 2 atria, which are at the top of the heart, receive venous blood—the left atrium receives oxygenated blood from the lungs via the pulmonary veins, and the right atrium receives deoxygenated blood from the rest of the body. A septum or wall separates the left side of the heart (atrium and ventricle) from the right side of the heart.

Blood enters the right atrium from the 2 largest veins in the body, the inferior vena cava, which collects blood from the lower part of the body, and the superior vena cava, which collects blood from the upper part of the body.

How does the heart work?
The heart is a pump that contracts 70- 80 times a minute and pumps 4300 gallons of blood a day. The heart rate is controlled by nerves that go to the heart.

The heart participates in 2 separate closed circulations, the pulmonary, delivering blood to the capillaries of the lungs by the action of the right heart, and the systemic, supplying blood to all other body tissues by the action of the left heart.

The lungs transmit oxygen from the air to hemoglobin in the red blood cells and remove carbon dioxide from the blood cells and breathe it out. The oxygenated blood goes from the lungs through the pulmonary veins to the heart. The heart sends this blood throughout the body through the arteries to every cell and receives the partially oxygenated blood containing carbon dioxide back through the veins. The force of the left ventricle can be felt on the left side of the chest.

The heart then pumps the oxygen-depleted blood back to the lungs through the pulmonary arteries, where the blood again picks up oxygen. This course of the blood to the lungs and back completes the cycle of the circulatory system.

What supplies the heart muscle with oxygen?
The heart has its own blood supply, the left and right coronary arteries, which come off the aorta just above the aortic valve and thus provide very oxygen-rich blood to the heart. The main branches of the left coronary artery are the circumflex and interventricular arteries. The coronary sinus is the main vein that carries blood from heart muscle back to the right atrium.

What are the heart valves?
The flow of blood from each chamber is controlled by a valve. As the valves open and close, they produce the characteristic lub-dub sounds heard with a stethoscope.
• mitral valve - between the left atrium and left ventricle
• aortic valve - between the left ventricle and the aorta
• tricuspid valve - between the right atrium and the right ventricle
• pulmonary valve - between the right ventricle and the pulmonary artery.

What are common valvular problems?
Valvular stenosis - a valve narrowed by disease. The blood pools behind a stenotic valve because of resistance to flow. The heart chamber in which the blood pools then becomes dilated or the muscle hypertrophies (enlarges) and the wall becomes thicker. For example, in mitral stenosis, the left atrium dilates. In aortic stenosis, the left ventricle hypertrophies.

Valvular regurgitation or insufficiency or incompetence - a valve distorted so that it closes incompletely. In aortic insufficiency, some of the blood that entered the aorta from the left ventricle flows back into the left ventricle. The left ventricle has to work extra hard to pump the same blood out twice, so it enlarges over time. Both stenosis and regurgitation may be present in the same valve.

What are the causes of valvular disease?
• congenital defects
• rheumatic fever and bacterial endocarditis
• degenerative changes
Rheumatic fever remains a common cause, but myocardial infarction is now the most common cause of mitral insufficiency. Rheumatic fever and syphilis were formerly the most common causes of aortic insufficiency (AI), but hereditary degenerative changes of the aorta now are a common cause. Tricuspid insufficiency is usually due to severe lung disease or pulmonary stenosis. Aortic stenosis may be due to rheumatic fever, may be congenital, or may be due to scarring and calcium in the aortic valve leaflets in the elderly.

What is rheumatic fever?
Rheumatic fever is a (usually) childhood illness that sometimes occurs after untreated strep throat (group A streptococcal throat infection). Can affect the heart (producing pancarditis, inflammation of all layers of the heart), joints (arthralgia or joint pain of multiple joints), brain (Sydenham’s chorea), or skin (characteristic rash called erythema marginatum). Heart involvement may be temporary or permanent.

What are the findings in valvular disease?
When valves are abnormal, heart sounds may be abnormal. There may be an extra sound called a murmur. The type and location of abnormal heart sounds often suggest a specific diagnosis, such as mitral stenosis. The signs and symptoms vary widely, depending on type, severity, duration, etc. The diagnosis may be made by stethoscope, echocardiography, cardiac catheterization, or angiography.

Valve replacement surgery removes the damaged heart valve and replaces it with a prosthetic device, an artificial valve that may be made of plastic, metal, and cloth or animal tissue.

What are the layers of the heart?
• endocardium - tissue lining the inside of the heart
• myocardium - muscle layer of the heart
• pericardium - outer covering of the heart
Any or all layers may undergo inflammation --- called endocarditis, myocarditis, and pericarditis, respectively. When all layers are inflamed, it is called pancarditis.

What is pericarditis and what causes it?
Pericarditis is an inflammation of the outer covering of the heart - acute or chronic. There are 2 layers of pericardial tissue, and fluid may form between them and either fluid or adhesions may compress the heart. If fluid accumulates rapidly, there may be cardiac tamponade—similar to shock—because the ventricles are compressed and become unable to pump adequately.

Some causes of pericarditis:
• infection, such as AIDS or other virus
• cancer from an adjacent area
• myocardial infarction
• trauma
• rheumatoid arthritis
• lupus erythematosus
• renal failure.
In chronic pericarditis, fibrous adhesions may compress the heart and interfere with its function, and the pericardium, which is not necessary for life, may need to be removed.

What is endocarditis and what causes it?
Endocarditis is an inflammation (often bacterial) of the endocardium and heart valves. Abnormal or damaged valves, such as those affected by rheumatic fever, are most susceptible. Also occurs in those with artificial heart valves, in congenital heart disease, and in injecting drug users.

When infection occurs, accumulations of bacteria and blood (called vegetations) form on the valves and can break loose and travel through the bloodstream as emboli to vital organs and block arteries causing, e.g., stroke. Treatment usually consists of at least 2 weeks of high-dose intravenous antibiotics.

How are the residuals of endocarditis and percarditis rated?
Since they may result in any of a variety of cardiac signs and symptoms, including heart failure, they are rated on the same criteria as arteriosclerotic heart disease and other major types of heart disease.

What are the general symptoms of heart disease?
As seen in the evaluation criteria for most types of heart disease, symptoms include dyspnea, fatigue, angina, dizziness (or lightheadedness), fainting (or syncope). However, each symptom could have another cause. For example, dyspnea might be due to lung disease, and dizziness to inner ear disease. We therefore require documentation that a specific disease is responsible for the symptoms.

What is arteriosclerosis?
Arteriosclerosis is the generic name for a group of diseases characterized by thickening of the walls of arteries by fatty deposits called plaques. The plaques narrow the lumen of the arteries, and the arterial walls lose their ability to stretch.

The types of arteriosclerosis are:
atherosclerosis - the most common type - affects large and medium-sized arteries. Is the underlying cause of most coronary artery disease, aortic aneurysm, peripheral vascular disease, and stroke
Monckeberg’s sclerosis, in which there is a heavy deposit of calcium in the muscular wall of arteries. It is usually clinically insignificant.
arteriolosclerosis, which is arteriosclerosis of the arterioles (the smaller arteries).

For rating purposes, arteriosclerosis and atherosclerosis can be considered the same thing.

How do we rate generalized arteriosclerosis, since there is no longer a code for it?
The effects of generalized arteriosclerosis are widespread. Many diagnostic codes, such as DC 7005, arteriosclerotic heart disease, DC 7114, arteriosclerosis obliterans, and DC 9305, multi-infarct dementia associated with cerebral arteriosclerosis, can be used to evaluate arteriosclerosis, depending on the specific organs involved.

What are papillary muscles and chordae tendinae?
Both ventricles contain finger-like projections of muscle bundles called papillary muscles. They are attached to the valves by fibrous cords called chordae tendinae.

At times one of these cords may rupture, possibly from arteriosclerosis, and mitral prolapse may result due to distortion of the valve. Therefore, arteriosclerotic heart disease (ASHD) may be a cause of mitral prolapse.

What is coronary artery disease (CAD)?
CAD is the most common type of heart disease. The coronary arteries can be affected by atherosclerosis in several ways.
• become progressively hardened and narrowed.
• become completely blocked (by plaque or a blood clot) (A clot can occur because fatty plaques produce an irregular wall.).
• wall becomes stretched, and an aneurysm develops.

Myocardial ischemia is the result of a decrease in coronary artery blood flow so great that the heart muscle doesn’t get sufficient oxygen. When ischemia develops, there may be no symptoms (silent ischemia), but angina or angina pectoris (chest pain), shortness of breath, or a myocardial infarction may occur. Ischemic heart disease (IHD) is another name for myocardial ischemia. It may be due to:
1. disease of the coronary arteries resulting in insufficient blood to supply the heart muscle.
2. myocardopathy or other condition where the heart muscle is enlarged so much that the coronary arteries, even if not severely narrowed, may be unable to supply the myocardium adequately because of its size.

What is angina?
Angina is a type of pain usually described as pressure, heaviness, tightness, or squeezing beneath the sternum. It usually lasts only a few minutes. Sometimes it radiates to the arms, shoulders, neck, or jaw. Normally, it occurs on exertion, on entering cold air, or with emotional stress. Symptoms usually develop only after a coronary artery is narrowed to less than 30% of its original size. However, spasm of a coronary artery (vasospasm) can also cause angina. Disease in and around the aortic valve can also cause angina because the aortic valve is near the entrance to the coronary arteries.

Once established, the pattern of angina usually stays the same. Unstable angina means the pain has become more severe, more frequent, or occurs with less exertion or at rest. It usually indicates a rapid progression of CAD.
Variant angina is characterized by pain at rest, rather than on exertion.

IHD is a presumptive condition for SC in former prisoners of war who had edema of the ankle, legs, or feet during captivity (note under 38 CFR 3. 309(c)).

It is likely that the edema and later heart disease in former POW’s are related to severe malnutrition, particularly beriberi, but this has not been proven. Despite the note stating that beriberi heart disease includes IHD, there is NO requirement that beriberi be diagnosed at any time during service or after in a former POW to grant SC for IHD. The only requirements are edema of the lower extremities during captivity and current IHD. The IHD maybe called arteriosclerotic heart disease, coronary artery disease, myocardial infarction, etc.

Remember, however, if a former POW is presumptively service-connected for ischemic heart disease (IHD), even if the IHD is ASHD, there is no basis to SC arteriosclerosis affecting any other part of the body, such as CVA, peripheral vascular disease, or aortic aneurysm.

How is CAD diagnosed?
For rating purposes, we require documentation of CAD. This may be based on:
1) ECG (electrocardiogram, also abbreviated EKG) findings,
2) treadmill exercise testing (with or without a thallium scan), or
3) cardiac catheterization and angiography - the “gold standard” - but not always necessary.

A clinical diagnosis of CAD without evidence on one of these tests is not sufficient for rating purposes because chest pain resembling angina has many possible causes other than heart disease.

If surgery is necessary, what types are used to treat CAD ?
1. Bypass surgery or coronary artery bypass surgery or grafting (CABG) For those with disabling angina who can’t be well-controlled by medical treatment.
A piece of a blood vessel, often from the chest (internal thoracic artery) or leg (saphenous vein) is removed and grafted between the aorta and the blocked artery, bypassing the blocked area. It may require use of a heart-lung machine, but recently some have been done without it (called off-pump CABG). This is used when a minimally invasive direct CABG (known as MIDCAB) is done.

2. Coronary artery (transluminal or balloon) angioplasty (often called percutaneous transluminal coronary angioplasty (PTCA)
Involves passing a fine catheter through an artery into the aorta and then into the blocked area of a coronary artery. The catheter has a balloon-like tip that is inflated to widen the artery and allow more blood to flow through. It is performed under local anesthesia and does not require use of a heart-lung machine.
Variations include
use of a tiny drill to clear away plaques
laser ablation (removal), in which a fiberoptic catheter is inserted into the artery and a laser beam is used to clear the plaque.
The wall of a coronary artery is often weak at the site where angioplasty was performed. Therefore, at times a stent, in the form of a metal coil, a cylindrical mesh, etc., which acts as a strut or scaffold, is inserted into a coronary artery to keep it from collapsing after angioplasty has been performed.

What is a myocardial infarction (MI)?
A myocardial infarction or “heart attack” or coronary occlusion or coronary thrombosis results when an area of heart wall muscle dies due to lack of oxygen. Most result from CAD. An MI may occur when an artery becomes completely blocked by plaque or by a thrombus (clot).

For rating purposes (under DC 7006), what serves as documentation of an MI? This is ordinarily based on one or more of the following:
EKG findings
cardiac enzyme elevation
special studies, such as radionuclide imaging.

How do we rate CAD (also called coronary heart disease (CHD) or arteriosclerotic heart disease (AHSD)?
CAD is rated under one of several codes, depending on whether a myocardial infarction has occurred or not, and whether surgery, such as a bypass procedure, has been performed. In some cases, a complication, such as an arrhythmia, may be the primary disability that requires rating.

Usually CAD causes angina on exertion or with stress. For evaluating CAD with angina, we use DC 7005 and evaluate based on one of several criteria. The basic criteria for evaluating most types of heart disease are METs values.

What are METs (metabolic equivalents)?
The principle behind using METS to assess heart disease is that the capacity of muscles to exercise depends on the ability of the cardiovascular system to deliver oxygen to the muscle. Therefore, measuring the exercise capacity can also measure how well the cardiovascular system performs. If the heart can’t deliver enough oxygen to allow various activities without symptoms developing, it is not functioning normally.

The most accurate way to measure exercise capacity is to determine the amount of oxygen, in liters per minute, transported from the lungs and used by skeletal muscle at peak effort. However, directly measuring the oxygen uptake on exercise is impractical, so we use multiples of the resting oxygen consumption or METs to determine the energy cost of physical activity.

One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute.
This is the resting energy requirement. With progressive activity, the number of METs required progressively increases. Two METs require twice the resting energy cost, and so on. For example:
A workload of three METs represents such activities as level walking, driving, and very light calisthenics.
A workload of greater than three METs but not greater than five METs represents such activities as walking two and a half miles per hour, social dancing, light carpentry, etc.

How are METs measured?
METs are measured by means of a treadmill exercise test (exercise tolerance test, stress test), the most widely used test for diagnosing coronary artery disease and assessing the ability of the coronary circulation to deliver oxygen according to the metabolic needs of the myocardium.

In this test, a patient is connected to an EKG monitor and asked to walk on a treadmill (or sometimes peddle a stationary bicycle or climb steps). The test ends when heart symptoms develop or the EKG shows ischemia. At times the test will be positive for CAD even though the person has been free of symptoms.
Some patients cannot tolerate a treadmill test because of medical problems such as:
• unstable angina with pain at rest
• advanced atrioventricular heart block
• uncontrolled hypertension.
For those cases, the following alternative criteria can be used to rate:
• cardiac hypertrophy or dilatation
• decreased left ventricular ejection fraction
• congestive heart failure.

[If unable to use a treadmill or bicycle because of orthopedic or neurologic problems, etc., a pharmacologic (non-exercise) stress test, in which drugs that stress the heart are injected, may be used instead.]

If none of the alternative criteria is present, and a treadmill test cannot be done for medical reasons, we will accept the examiner's estimation of the level of activity, expressed in METs, and supported by examples of specific activities, such as slow stair climbing, or shoveling snow, that result in dyspnea, fatigue, angina, dizziness, or syncope.

Are METs the determining factor in rating if other findings support a higher evaluation? For example, the examiner shows METs as 7, which would be a 30% evaluation, and also reports left ventricular dysfunction with an ejection fraction of 50%, which would warrant a 60% evaluation. No, the criteria more beneficial to the veteran should be used. The criteria have equal weight. In the example, the correct rating would be 60% based on the left ventricular ejection fraction.

Old system - NYHA classification. The NYHA classification, a somewhat subjective older method of classification, is not a sensitive measure of health-related quality of life.

What are the alternative criteria for evaluating CAD?
1. Left ventricular ejection fraction:
• Represents the force with which a ventricle ejects blood from the heart with each beat of the heart.
• Normal ejection fraction is 55-65%. The lower the number, the harder the heart has to work to supply the body with sufficient oxygen.
• Measured by using radionuclide ventriculography—a MUGA scan (multi-gated acquisition scan). In this process, a radioactive substance (technetium-99m) is injected into a vein, and the radioactive material is traced to determine the ejection fraction.
2. Cardiac hypertrophy or dilatation shown on EKG, echocardiogram, or X-ray.
3. Congestive heart failure (CHF). When the heart muscle is damaged due to CAD or MI’s, it may enlarge or hypertrophy as the undamaged areas work harder. Beyond a certain point, the result is decreased pumping ability and heart failure.

Do we require that an exam provide a METs assessment plus an ejection fraction measurement plus an X-ray to evaluate heart disease properly? No. Ordinarily, if you have an ejection fraction that warrants 60 or 100%, you can rate on that. If you have a treadmill test with METs, you can rate on that. If there is CHF, you can rate at 60 or 100% based on that. If there is heart enlargement on X-ray, you can rate at a minimum of 30% based on that, but you should also have a METs assessment in case it warrants a higher evaluation.

What is congestive heart failure (CHF)?
CHF is a decrease in the heart’s ability to pump an adequate amount of blood. It occurs when the heart muscle is damaged or overworked. With less blood leaving the heart, blood returning to the heart gets backed up and fluid collects in the lungs and liver and can seep into surrounding tissues and cause edema.

Effects of CHF:
a) The heart doesn’t stop pumping, as in cardiac arrest.
b) Blood pools in the veins, especially the legs and ankles, causing edema.
c) Fluid backs up into the lungs, causing pulmonary edema with dyspnea (shortness of breath), orthopnea (shortness of breath on lying down), cough, and pleural effusion (fluid in the pleural space surrounding the lungs).
d) There may be weight gain and abdominal fluid, and the liver may enlarge because of congestion. Pleural effusion may develop.
e) The heart rate is usually rapid, as the heart tries to compensate for ineffective pumping by speeding up, and the heart is usually enlarged.
f) Easy fatigue and weakness occur.

In right-sided heart failure, fluid backs up into the body from the right atrium, leading to edema of the legs, enlarged liver, etc. In left-sided heart failure, fluid backs into the lungs from the left atrium causing pulmonary edema or congestion. Left-sided and right-sided heart failure almost always occur together, but failure of one side may predominate.

The five-year survival rate in someone with congestive heart failure is 50%.

How do we rate CHF?
As the survival rate indicates, CHF is a serious heart problem and is rated accordingly, at 60% if there has been more than one episode of CHF in the past year, and at 100% if there is chronic CHF.

If both SC RHD and non-SC ASHD are present, ask for a medical opinion as to which condition is causing the current signs and symptoms. Mitral stenosis was formerly diagnosed casually, often in anyone who had had RF (and sometimes in those who had not) who had a murmur. Murmur alone is not indicative of disability.

When is cardiac transplantation carried out?
When end stage heart disease of various types does not respond to treatment, and the patient is in good health otherwise, cardiac transplantation may be recommended.

How often are cardiac transplants done, and how successful are they?
The first human heart transplant was December, 1967. The one year survival rate is 82.5%; at 4 years it is 70.5%. About 85% return to work, school, etc. The greatest risks of cardiac transplant are from rejection or infection.

What types of heart disease may lead to cardiac or heart/lung transplants?
Cardiomyopathy, severe CAD, and congenital heart defects are the most common reasons for cardiac transplants.

Heart/lung transplants are most often done for severe pulmonary hypertension and a congenital heart disease that causes similar findings.

Combined heart and lung transplants have been done since 1981. About 60% of heart/lung transplants live at least 1 year after surgery.

What happens after cardiac transplant surgery?
Immune cells recognize the transplanted organ(s) as different from the rest of the body and attempt to destroy it; this is called rejection. If left alone, the immune system would damage the cells of a new heart and eventually destroy it.

To prevent rejection, patients receive immunosuppressants, drugs that suppress the immune system so that the new organ is not damaged. The three main drugs now used are cyclosporine, azathioprine, and prednisone. Side effects may include hypertension, fluid retention, tremors, excess hair growth, osteoporosis, lymphoma, and kidney damage.

Without an active enough immune system, a patient can easily develop severe infections. For this reason, medications to fight infections are also prescribed.

Biopsies of the heart muscle are usually performed weekly for the first 3 to 6 weeks, every 3 months for the first year, and yearly thereafter.

The transplanted heart beats faster and responds more slowly to exercise than a normal heart. About half of people with cardiac transplants develop CAD, and up to half develop lung problems.

What is cor pulmonale?
Cor pulmonale is enlargement or hypertrophy of the right ventricle due to pulmonary hypertension (elevated blood pressure in the lungs). It is a complication of disorders that slow or block blood flow in the lungs.

Clinically, it presents as right heart failure, with edema of the legs, enlarged liver, pleural effusion, etc. It may develop acutely (e.g., due to a pulmonary embolus) or slowly, due to pulmonary disease such as COPD or heart disease such as mitral valvular disease.

Normally, the right side of the heart is weaker than the left side. The blood pressure in the pulmonary arteries is therefore lower than the blood pressure in arteries elsewhere. In severe lung disease such as emphysema, it becomes harder for the heart to pump blood through the lungs, so the pressure in the lungs increases and the heart works harder. The right side of the heart enlarges to compensate, but right-sided heart failure usually develops.

How do we rate cor pulmonale? Per the note at beginning of § 4.104, cor pulmonale, although it is a heart problem, is evaluated in the respiratory system under the pulmonary condition causing it.

What are the nerve supply and conduction system of the heart/
The nervous system of the heart, including the special conduction system that regulates the heartbeat, is made up of fibers from both sympathetic and parasympathetic nerves from the autonomic nervous system. It consists of:
sinoatrial (SA) node (or sinus node)
atrioventricular (AV) node
atrioventricular Bundle of His

The heartbeat starts in the wall of the right atrium in the SA node, also called the natural pacemaker of the heart. The AV node is also in the wall of the right atrium, some distance from the SA node, near the bottom of the atrium. The atrioventricular bundle of His is in the interventricular septum. It divides into left and right bundle branches. The Purkinje fibers are the conducting fibers that innervate the myocardium.

The signal for the heartbeat starts in the SA node, progresses to the AV node, and goes through the bundle of His and Purkinje fibers, which send an electrical impulse to the ventricles. Heart rate is also influenced by the sympathetic nervous system hormones epinephrine (adrenaline) and norepinephrine (noradrenaline).

The normal heart rate is 60-100 beats per minute, although athletes may have lower rates. When the heart rate is inappropriately fast (tachycardia = >100 beats per minute) or slow (bradycardia = <60 beats per minute) or when the electrical impulses travel in abnormal pathways, the heartbeat is considered to have an abnormal rhythm (arrhythmia). Abnormal rhythms may be regular or irregular.

What are the basic causes of arrhythmias?
The heartbeat begins somewhere other than the SA (sinus) node.
The SA node develops an abnormal rate or rhythm.
There is a heart block.

What are the specific causes of arrhythmias?
The main causes are heart disease, particularly CAD, valvular heart disease, and heart failure.

At times, no underlying heart disease or other cause is found. Arrhythmias that arise without heart disease may be related to stress, tobacco, caffeine, diet pills, and certain cough and cold medicines.

There are supraventricular, ventricular, and atrioventricular types. Those arising in the ventricles are usually more serious. Most people have experienced sinus arrhythmia, which is a normal change in heart rate, particularly common in children, during inspiration. In sinus tachycardia, the heart rate is fast because the sinus node sends out the signal faster than usual. Simple exercise can lead to sinus tachycardia, as can thyroid disease.

How are arrhythmias diagnosed?
Arrhythmias are usually diagnosed on an EKG. When there are symptoms of an arrhythmia, such as palpitations or fainting, and the routine EKG is normal, a continuous 24-hour EKG recording (Holter monitor) may be used while the individual carries out his or her normal activities.

What are the supraventricular arrhythmias?
Atrial ectopic beat or premature atrial (or supraventricular) contraction (PAC)
PAC is an extra heartbeat before the next regular heartbeat. It is caused by early electrical activation of the atria. They occur in healthy people and rarely cause symptoms.

Paroxysmal atrial (or supraventricular) tachycardia (SVT or PAT)
• Regular, rapid (160 to 200 beats per minute) heart rate.
• Sudden onset and stop.
• Due to a series of early beats in the atria.
• May last a few minutes or up to many hours.
• Uncomfortable palpitations occur and sometimes weakness.
• Usually, the heart is otherwise normal.

Atrial fibrillation and atrial flutter
• Extremely rapid atrial contractions (400 to 600 times/minute) that cause the ventricles to contract faster and less efficiently than normal (170 to 200 times/minute).
• May be intermittent or persistent.
• In flutter, the atrial and ventricular rhythms usually are rapid but regular.
• In fibrillation, the atrial rhythm is irregular, so the ventricular rhythm is also irregular.
• In both, the ventricles beat more slowly than the atria because the atrioventricular node and the bundle of His can't conduct electrical impulses at such a fast rate.
• Because of the rapid ventricular rate, inadequate amounts of blood are pumped, blood pressure falls, and heart failure may occur.
• May occur without heart disease but may be due to rheumatic heart disease, CAD, hypertension, alcohol abuse, or hyperthyroidism.

When atrial fibrillation is present, blood inside the atria may stagnate and clot. Pieces of the clot may break off, pass into the ventricle, and go out into the general circulation (or lungs), where they may block a smaller artery (as emboli). An embolism to the brain may cause a stroke. Individuals with atrial fibrillation are often maintained on anticoagulants to prevent such events.

What is Wolff-Parkinson-White (WPW) syndrome?
WPW syndrome is an abnormal heart rhythm in which electrical impulses are conducted along an extra pathway that is present from birth. It causes occasional episodes of a very rapid heart rate with palpitations. It may show up as early as the first year of life or as late as age 60. If it is service-connected, DC 7010 would be the appropriate code for rating.

What are the ventricular arrhythmias?
Ventricular ectopic beat, or premature ventricular contraction or complex (PVC), or ventricular extra-systole:
• An extra heartbeat caused by electrical activation of the ventricles before the normal heartbeat. The heart then seems to pause until the next beat.
• Are common, occurring occasionally in almost everyone.
• When they occur frequently in a person who has heart failure or aortic stenosis or who has had a heart attack, they may be followed by more dangerous arrhythmias such as ventricular fibrillation, which can cause sudden death.
• The main symptom is feeling a strong or skipped beat.

Ventricular tachycardia:
Is a ventricular rate of at least 120 beats per minute triggered in the ventricles, usually with palpitations. Transient is not as significant as sustained.

Ventricular fibrillation - electrically similar to atrial fibrillation, but is much more serious:
• The ventricles contract ineffectively and only quiver instead of pumping blood. No blood is pumped from the heart. It is a form of cardiac arrest and is fatal unless treated immediately.
• The main causes are CAD or MI.
• It leads to unconsciousness in seconds, then convulsions and irreversible brain damage after about 5 minutes because oxygen is not reaching the brain. Death soon follows.

What is heart block?
Heart block is a condition in which the electrical signal cannot travel normally down its usual pathway to the ventricles. For example, the signal may be delayed or partly or completely blocked. If completely blocked, the beat originates in the ventricles and is usually very slow. There are first-degree, second-degree, and third-degree heart blocks, depending on whether conduction to the ventricles is slightly delayed, intermittently delayed, or completely blocked.

First-degree heart block produces no symptoms. It is common among well-trained athletes, teenagers, young adults, and people with a highly active vagus nerve. However, it also occurs in rheumatic fever and sarcoid heart disease and may be caused by drugs. The diagnosis is made by EKG. It requires no treatment even when it's caused by heart disease.

In second-degree heart block, the heart beats slowly or irregularly and sometimes requires an artificial pacemaker.

In third-degree heart block, impulses from the atria to the ventricles are completely blocked, and the ventricles beat less than 50 beats per minute. This can affect the heart's pumping ability, so syncope, dizziness, and sudden heart failure are common. Third-degree block almost always requires an artificial pacemaker.

What is sick sinus syndrome?
Sick sinus syndrome includes a wide variety of abnormalities of natural pacemaker (AV node) function. It may result in a persistently slow heartbeat (sinus bradycardia) or a complete blockage between the pacemaker and the atria (sinus arrest) in which the impulse from the pacemaker fails to make the atria contract. It is treated by a permanent pacemaker and sometimes drugs.

What are bundle branch blocks (BBB’s)?
These are EKG findings that sometimes, but not always, indicate heart disease. They represent delays in the electrical conduction of the heart. There are left bundle branch blocks (LBBB) and right bundle branch blocks (RBBB).

RBBB occurs in many healthy individuals, but acute onset frequently occurs with acute anteroseptal myocardial infarction. The new appearance of RBBB may also suggest other cardiac conditions (sarcoid of the heart, etc.).

LBBB may also occur in healthy individuals, either from birth or developing in adulthood. However, LBBB can be caused by CAD, valvular heart disease, or other types of heart disease. It may predispose to developing a very slow heart rate, which manifests itself as dizzy spells or passing out.

Do we rate BBB’s?
Only if disabling, e.g., cause syncope. Otherwise, the underlying heart disease (usually CAD or MI) is rated. If there are no symptoms, and no heart disease is identified other than their presence on an EKG, they are not disabilities.

What are the treatments for arrhythmias?
• No treatment is needed in many.
• Drugs.
• Pacemakers - electronic devices implanted beneath the skin below the collarbone that regulate the heartbeat. They have tiny electrodes leading to the right heart. Most modern pacemakers can function for 8 to 12 years before the batteries require replacement.
• Implantable cardiac defibrillators - placed inside the chest. They use an electric shock to restore normal rhythm in certain serious ventricular tachycardias that can lead to sudden death. They decrease the expected mortality rate from 50% to 2% in the first 2 years after implant.
• Surgical ablative techniques - if an arrhythmia is caused by an abnormal area of heart muscle that can be removed. Done via open-heart surgery or more recently through a catheter using electrocautery.
• Cardioversion - change of heart rhythm back to normal, either through medication or an electrical shock to the chest wall

What is mitral valve prolapse (MVP)?
Mitral valve prolapse (MVP), also called floppy valve syndrome, is a condition in which the mitral valve leaflets are stretched or misshapen or bulge out, so the valve does not close properly and does not allow blood to flow only in one direction, into the left ventricle, as it normally does.

Although most are congenital, it is usually not diagnosed until adulthood. Therefore it will often be found for the first time in service. At times there is some mitral regurgitation, or flow of blood back into the left atrium. A click or a murmur, or both, may be heard.

Causes include congenital and idiopathic (most); connective tissue diseases, such as systemic lupus erythematosus; muscle disorders, such as myotonic dystrophy; congenital heart disease, such as atrial septal defect; and acquired heart disease, such as a ruptured chordae tendinae, injury to the heart, mitral valve surgery, or rheumatic endocarditis.

How is MVP diagnosed?
By the characteristic heart sound of a click or murmur or through echocardiography. EKG is usually normal.

What are the symptoms of MVP?
Most have no symptoms, and the condition is benign and nonprogressive.
But up to 40% have palpitations, and some may have shortness of breath, dizziness, or, rarely, chest pain, but the relationship of any symptoms other than palpitations to MVP is uncertain.
Occasionally, there are serious complications, such as endocarditis, arrhythmias, stroke, or sudden death.

What is the treatment of MVP?
Most need no treatment, but some need medication.

Can MVP be service-connected?
If diagnosed for the first time in service, and symptomatic, it can be service connected, even if believed to be congenital. It could also be SC if it doesn’t develop until after service if it develops secondary to a service-connected condition such as lupus erythematosus. Without symptoms, it is a finding but not a disability.

How would MVP be rated?
Its evaluation would vary, depending on the particular signs and symptoms. In most cases, it will probably warrant only a 0% evaluation. However, if continuous medication is required, 10% might be warranted, and if it causes an arrhythmia or endocarditis, a higher evaluation still might be warranted.

MVP is the third most common cause of sudden death in athletes, after hypertrophic cardiomyopathy and congenital anomalies of the coronary arteries.

What is cardiomyopathy?
Cardiomyopathy is a condition that affects the heart muscle of the ventricles. There are 2 common types.
Dilated congestive cardiomyopathy
• the most common type.
• the heart cavity is stretched and enlarged.
• most commonly due to CAD, but also from viral infections and drugs such as alcohol, cocaine, and antidepressants.
• first sign may be congestive heart failure.
• about 70% die within 5 years.
• treatment is antiarrhythmic drugs, pacemaker, or, in severe and progressive cases, heart transplant.

Hypertrophic myocardopathy
• congenital or secondary to other diseases.
• heart wall is thickened and enlarged.
• in one type the wall between the ventricles is thickened (hypertrophic obstructive cardiomyopathy or asymmetric septal hypertrophy, or idiopathic hypertrophic subaortic stenosis (IHSS)). This obstructs the blood flow from the left ventricle.
• arrhythmias, heart failure, and sudden death may occur
• beta-blocker drugs or surgery are the treatments.

What is hypertension and what causes it?
Hypertension is present if the diastolic blood pressure is 90 mm Hg or more or the systolic pressure is 140 mm Hg or more, or if both are present. In isolated systolic hypertension, the systolic pressure is 140 mm Hg or more, but the diastolic pressure is less than 90 mm Hg. Malignant hypertension is a severe form of high blood pressure that, if left untreated, usually leads to death in 3-6 months.

For rating purposes, we consider isolated systolic hypertension to be present if the systolic pressure is 160 or more. The level of blood pressure considered to be normal has been progressively lowered in recent years.

Some risk factors for essential hypertension (hypertension without an underlying cause) are:
smoking
dyslipidemia (abnormal serum fats)
family history
obesity
sedentary lifestyle
high salt intake.
In a few cases, known as secondary hypertension, there is a specific underlying cause, such as renal artery stenosis, pyelonephritis, glomerulonephritis, or other kidney or adrenal gland disease, or a congenital coarctation (narrowing) of the aorta.

What are the symptoms and complications of hypertension?
Most people with hypertension have no symptoms. However, with long-standing or untreated hypertension, there may be damage to certain end organs (eyes, kidneys, heart, brain), resulting in symptoms such as headache, blurred vision, fatigue, shortness of breath, chest pain, and many others.

The Committee considers a systolic pressure of <120 and diastolic pressure of <80 to be optimal, systolic pressure of <130 and diastolic of <85 to be normal, and systolic pressure of 130-139 and diastolic of 85 to 89 to be high normal.

How do we rate hypertension?
The criteria for 7101 are based only on blood pressure readings and whether continuous medication is required in someone with a history of diastolic pressure predominantly 100 or more. Remember to separately rate secondary conditions affecting target organs.

• Multiple BP readings are required to confirm the diagnosis of hypertension. Rating schedule requires 2 or more readings on at least 3 different days.
• However, once hypertension has been properly diagnosed, readings on multiple days are not required for follow-up.
• If the veteran is on treatment for hypertension at the initial exam, multiple readings on different days are not necessary because they would not be useful

For new claims, the required multiple readings should already be of record because this is a standard requirement for diagnosis and treatment. If not, the diagnosis of hypertension is suspect.

If a veteran had the diagnosis of hypertension at discharge or in service, but never had multiple readings in service to confirm, the initial exam should establish or confirm the diagnosis by means of 2 or more readings on at least 3 different days, if the veteran is not on treatment.

What is the relationship of hypertension to diabetes?
They are frequently present in the same individual, but, in general, the type of hypertension that is present in diabetics is essential or primary hypertension and is not due to diabetes. However, some diabetics develop a complication called diabetic nephropathy that damages the kidneys, resulting in a type of renal (or secondary) hypertension. Diabetic nephropathy is usually indicated by proteinuria (protein in the urine), specifically albuminuria.

Both hypertension and diabetes are risk factors for arteriosclerosis, so if both are present, the development and progression of arteriosclerosis tends to be accelerated.

Under 38 CFR 3.310(b), is arteriosclerosis included as “a cardiovascular disease” that is the proximate result of an AK amputation and that would therefore warrant SC? Yes. 3.310(b) does not exclude any disease of the cardiovascular system (including venous diseases).

The legs contain two major groups of veins: the superficial veins, located in the fatty layer under the skin, and the deep veins, located in the muscles. Short veins connect the superficial and deep veins. Veins have one-way valves that help propel the blood back to the heart. Compression of the calf muscles, as in walking, also propels the blood upward toward the heart.

What is deep vein thrombosis?
Thrombophlebitis is inflammation and clotting in a vein. A clot that forms in a blood vessel is called a thrombus. Thrombi can occur in either the superficial or deep leg veins, but only those in the deep veins are potentially dangerous, because the thrombus can break loose (as an embolus) and move into the bloodstream, and lodge in an artery in the lung, causing a pulmonary embolus and infarct.

Causes:
• injury to the lining of the vein
• an increased tendency for blood to clot, as can happen with some cancers and rarely with oral contraceptive use
• slowing of the blood flow in the veins, as happens during prolonged bed rest, long flights or drives, etc.

Signs and symptoms:
• no symptoms in half - pulmonary embolism may be the first sign.
• calf may swell and may be painful, tender to the touch, and warm.
• ankle, foot, or thigh may also swell, depending on which veins are involved
• when chronic - brown skin discoloration above the ankle and sometime ulceration.

What are varicose veins?
Varicose veins are enlarged superficial veins in the legs. The precise cause is not known, but is probably a hereditary weakness in the walls of the superficial veins. Sometimes are due to phlebitis.

The weakness causes veins to stretch and elongate and become tortuous. The symptoms are tired, heavy, or aching legs, and only a small percentage of people have complications, such as dermatitis, phlebitis, bleeding, or ulcers.

How do we rate the disabling effects of thrombophlebitis?
Thrombophlebitis is usually an acute condition that won’t present for rating. If an embolus develops during the course of thrombophlebitis and leads to a pulmonary infarct, we would rate the residuals.

We may see a chronic form of venous insufficiency known as "postphlebitic leg," "postphlebitic sequelae of chronic venous insufficiency," "postphlebitic syndrome," or "stasis syndrome" due either to varicose veins or thrombophlebitis. The postphlebitic syndrome may itself lead to the development of varicosities because of chronic venous insufficiency, and varicosities can lead to postphlebitic syndrome.

The effects of chronic venous insufficiency (swelling, eczema, stasis pigmentation, etc.) are the basis of evaluating venous insufficiency from either cause, because the same findings can occur from both.

What is an arteriovenous fistula (A-V fistula)? (called arteriovenous aneurysm, now an obsolete name, in the former schedule)
Blood flows directly from an artery into a vein, bypassing the capillaries. It may result from any injury that damages an artery and a vein lying side by side, most commonly a wound from a knife or bullet.

Symptoms may be limited to the local site of the fistula and include edema, dermatitis, ulceration, or cellulitis. But if a large A-V fistula isn't treated, blood flowing under high pressure from the artery into the vein may strain the heart, causing heart failure (high output failure). Treatment is surgery or destruction by laser coagulation therapy.

How are arteriovenous fistulas rated?
They are rated based either on local signs and symptoms in the extremity affected, or, in the more serious cases where there is heart strain, on heart involvement, such as heart enlargement or failure.

What are the abnormal conditions of the aorta?
• aneurysms - most in abdominal aorta, due to atherosclerosis, may rupture
• ruptures and hemorrhage - often fatal
• dissection - separation of the layers of the wall that allows blood to collect between the layers.
Diagnosis of aortic aneurysm:
a) May be made on the signs and symptoms on a routine examination, but may require abdominal x-ray, ultrasound scan, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, or aortography (an X-ray of the aorta with dye injected).
b) Treatment is surgery with a graft for abdominal aneurysms greater than 2 inches in diameter (approximately 5 cm.) because of the risk of rupture.

Other arterial aneurysms
An aneurysm is a localized abnormal dilation of any artery.

Berry aneurysm - small (<1.5 cm diameter), congenital aneurysm of brain. Rupture leads to subarachnoid hemorrhage. Can be cured by being clipped.

Left ventricular aneurysms
Develop in 10-38% after MI when part of damaged heart wall becomes scarred and weakened.
May cause shortness of breath, chest pain, or arrhythmia and may require ventricular aneurysmectomy if causes CHF or arrhythmia.

How are aortic aneurysms rated?
a) Zero percent if not symptomatic, less than 5 cm. in diameter, and does not require curtailing of activities (preclude exertion).
b) If activities restricted to exclude exertion, 60%.
c) If 5 cm. or greater in diameter or symptomatic, 100%.
d) Arteriosclerosis is the usual cause - may be secondary to hypertension or diabetes mellitus.

Cardiovascular syphilis (DC 7004)(DC 7110 for aneurysm)
Caused by spriochete treponema pallidum. Tertiary syphilis is a late stage of the disease, occurring from 10-25 years after the primary infection.

Common problems - aneurysm of the transverse or ascending aorta, narrowing of the openings to coronary arteries, and aortic valvular insufficiency.

What is arteriosclerosis obliterans (peripheral arterial disease, peripheral vascular disease, PVD)?
PVD is a narrowing of the arteries, usually due to atherosclerosis. The main symptom is intermittent claudication. This is a painful, aching, cramping, or tired feeling in leg muscles during physical activity. It is generally in calf, but foot, thigh, hip, or buttocks possible. It is relieved by rest, and after rest for 1-5 minutes, can walk the same distance before pain again. A similar pain on exertion can occur in the arms if arteries are narrowed.

Diagnosis of PVD:
• symptoms, decreased or absent pulse below a certain point in the leg.
• ankle-brachial index (ABI) - compares systolic blood pressure at the ankle with systolic blood pressure in the arm. The lower the index, the more severe the occlusion of the artery. Divide the ankle systolic blood pressure by the brachial systolic pressure to determine the ankle-brachial index. Equation: A/B = ABI. The ankle pressure is normally 90% of the arm pressure, or 0.9 or greater.
◊ 0.7 to 0.9 = mild arterial insufficiency or obstruction.
◊ 0.5 to 0.7 = moderate disease.
◊ less than 0.5 = severe arterial occlusive disease.
• Doppler ultrasound - probe is placed on the person's skin over the site of obstruction, and the sound of the blood flow indicates the degree of obstruction.
• angiography to show the rate of blood flow, diameter of the artery, and obstruction. May be followed by angioplasty to open up the artery.

Treatment of PVD:
Includes increased walking, drugs, angioplasty, surgery.
Surgery may include:
• removal of clot if a small area is blocked
• bypass graft - tube made of a synthetic material or a vein from another part of the body is joined to the obstructed artery above and below the obstruction.
• removal of blocked or narrowed section with insertion of graft
• sympathectomy - cutting the nerves near the obstruction
• amputation - for infection, unrelenting pain, or worsening gangrene

How is peripheral arteriosclerosis of the extremities rated?
Rating (under DC 7114) is based either on the ABI or the extent of walking that results in claudication. In addition, deep ulcers plus pain at rest warrant a 100% evaluation.

If bypass surgery or arterial grafting has been performed, rating is based on the same criteria.

If more than one extremity is affected by arteriosclerosis obliterans, each is separately evaluated, and their evaluations are combined. The bilateral factor must also be applied when appropriate.

What is Buerger’s disease?
• Buerger's disease (thromboangiitis obliterans) is the obstruction of small and medium-sized arteries and veins by inflammation. Mostly occurs in men (95%) who smoke cigarettes.
• It is not a type of arteriosclerosis. It represents an inflammatory response in the arteries, veins, and nerves, which leads to a thickening of the blood vessel walls.
• Symptoms begin at fingertips or toes and progress up the arms or legs. About 40% also have episodes of phlebitis. Some have Raynaud's phenomenon. With more severe obstruction, ulcers, gangrene, or both may appear.

How is Buerger’s disease rated?
Evaluation is identical to arteriosclerosis obliterans. If Raynaud’s phenomenon is present, it may be separately rated as long as the same signs and symptoms are not rated twice.

Do the 100% ratings we can give for peripheral arterial disease comply with the amputation rule (38 CFR 4.68)? § 4.68 is part of the musculoskeletal system. Its intent appears to be to limit evaluations for combinations of musculoskeletal disabilities. The former rating schedule allowed a 100% rating for a cardiovascular condition of a single extremity in thrombophlebitis (DC 7121). Any malignancy of an extremity did and does still warrant 100%. Therefore, § 4.68 does not apply to vascular or other non-musculoskeletal conditions of the extremities, and evaluations of 100% in extremities with vascular conditions do not violate 4.68.

Does a 100% rating for arteriosclerosis obliterans or other vascular disease of an extremity necessarily mean there is loss of use? No. This needs to be determined on a case-by-case basis, as always. For example, someone with Buerger’s disease may have a leg that meets all of the criteria for 100% but still be able to walk unassisted and with sensation intact. This would not equate to loss of use. On the other hand, someone with varicose veins warranting 100% might have massive painful edema that prevents ambulation and impairs sensation. In that case there could be loss of use.

What is Raynaud’s disease or syndrome?
Raynaud's disease and Raynaud's phenomenon or syndrome are conditions in which small arteries (arterioles), usually in the fingers and toes, go into spasm, causing a characteristic attack lasting minutes to hours. It may also affect the nose, earlobes, or lips. Color changes in the digits of white, red, and blue occur, not necessarily in a particular order. Episodes are often precipitated by cold or emotional stress. Most occur in women, 18 to 30.

In Raynaud's disease, there is no underlying cause. This is the milder form, and it usually affects both hands and feet. In Raynaud's phenomenon, although the signs and symptoms are the same, an underlying cause is known. It usually affects either both hands or both feet. Causes include scleroderma, rheumatoid arthritis, lupus erythematosus, atherosclerosis, nerve disorders, and reactions to certain drugs.

In long-standing Raynaud's phenomenon (especially with scleroderma), the skin of the fingers or toes may become smooth, shiny, and tight, and small, painful sores may appear on the tips of the fingers or toes.

How is Raynaud’s disease rated?
Rating under DC 7117 is based on the frequency of characteristic attacks and whether there are ulcers or autoamputation of one or more digits.

What is the course of Raynaud’s?
40-60% respond to management techniques, but autoamputation (self detachment of digit because of dry gangrene) may occur in a few severe cases.

What is angioneurotic edema (or angioedema)?
Giant hives thought to be due to allergy to a specific food or drug or to emotional stress. A hereditary type may occur without specific cause. It may be life-threatening when it affects the throat or larynx, since it may obstruct breathing.

Rating is based on the frequency and duration of attacks and whether there is laryngeal involvement.
What is erythromelalgia (DC 7119)?
Erythromelalgia is a pain syndrome of the skin. There are 5 main signs:
1) intense burning and tingling pain of the hands and feet
2) erythema (redness of skin)
3) increased skin temperature at affected sites
4) aggravation of symptoms by warmth
5) symptomatic relief by cooling or aspirin.

Mostly idiopathic, and some are congenital. Occasionally due to:
myeloproliferative disorder
rheumatoid arthritis or other collagen vascular disorder
diabetes mellitus
cancer
pernicious anemia
Rating is based on the frequency and duration of attacks and their response to treatment.

Cold Injuries
• Frostbite is freezing of tissue. Ice crystals form and draw water from the cells, causing cellular dehydration. This, with constriction of blood vessels, causes tissue injury.
• Skin and muscle are more prone to freezing damage than tendons and bones.
• Frostnip is a temporary paleness and numbness of exposed parts.

All residuals of cold injury can be evaluated either under DC 7122 itself, or under other appropriate codes for specific residuals, such as peripheral neuropathy, skin conditions, Raynaud’s phenomenon.

Must there be continuity of symptoms of cold injury following a cold injury for SC?
No. In fact, typically there are symptoms (swelling, pain, discoloration, etc.) for days up to a week or 2 after the cold injury. Unless there was loss of parts of the hands or feet, this is followed by a long latent (symptom-free) period. Then, years later, late or delayed signs and symptoms may start. These residuals may include numbness, pain, arthritis of the toes, etc. (all of the problems included in the rating criteria). There are veterans, however, who do have continuous problems after cold injury. These might include excessive sweating (hyperhidrosis), pain, numbness, or fungus infections, for example.

What are the “nail abnormalities” referred to in DC 7122 as residuals of cold injury residuals? These include distortion or loss of the nail or fungal infection.

For the most up-to-date and comprehensive discussion of cold injuries, especially late residuals of cold injuries, see the cold injury video and booklet. The booklet is available online at http://vaww.valu.lrn.va.gov/cold.

Some tests and procedures used in diagnosing heart disease

electrocardiogram (ECG or EKG) - a device that amplifies and records electrical impulses in the heart on a moving strip of paper. Small metal electrodes are taped on the skin of the chest, arms, and legs. Each is connected to the machine, which produces a tracing for each electrode. Each tracing reveals a particular view of the heart’s electrical patterns, called a “lead.”
Uses: arrhythmias, CAD, hypertrophy of heart muscle, MI.

Exercise tolerance testing (stress test) - monitors BP and EKG during exercise such as walking on a treadmill or pedaling a stationary bicycle at a given pace, which is gradually increased. Normally, the person can exercise until heart rate reaches 80 to 90% of maximum for age and sex. If symptoms develop or EKG changes appear, the test is ended. There can be both false positives and false negatives.
Uses: diagnose existence and severity of CAD and other heart disorders.

Continuous ambulatory electrocardiography - person carries a small battery-powered device – the Holter monitor - that records the EKG for 24 hours. The patient records the time of any symptoms. A computer analyzes the recording.
Uses: to detect arrhythmias or CAD when they occur only briefly or unpredictably.

Transtelephonic monitoring - patient wears EKG recording device over days or weeks. When the patient suspects an arrhythmia, he or she telephones a monitoring station which will record the EKG.
Use: to reveal arrhythmias that occur only occasionally.

Electrophysiologic testing - tiny electrodes are inserted through veins or arteries into the heart, to record the EKG from within the heart.
Uses: to evaluate serious rhythm or electrical conduction abnormalities.

X-rays
Uses: determine size and shape of heart and outline blood vessels in lungs and chest. Show fluid in or around the lungs.

Fluoroscopy - continuous X-ray procedure that shows movement of heart and lungs.
Uses: less used today because of the high dose of radiation it produces, but assists in cardiac catheterization and electrophysiologic testing.

Echocardiography - uses high-frequency ultrasound waves emitted by a recording probe (a transducer) and bounced off the structures of the heart and blood vessels to produce a moving image that appears on a video screen.
Uses: detect abnormalities in heart wall motion, volume of blood pumped, status of pericardium, and, if Doppler type is used (rather than the basic “M” mode or two-dimensional type), if valves open and close properly.

Magnetic resonance imaging - uses a powerful magnetic field to create detailed images. Person is placed inside a large electromagnet that causes atomic nuclei in the body to vibrate and give out characteristic signals, which are converted into 2- or 3-dimensional images.

Radionuclide imaging (or myocardial perfusion scan) - minute amounts of radioactively labeled substances (tracers) (usually thallium-201) are injected into a vein. The tracers are quickly distributed through the body, including the heart. Then they are detected by a gamma camera (scanner) that obtains images while the person performs an exercise test. An image is displayed on a screen. If an acute MI is suspected, tracers containing technetium 99m are used because technetium accumulates primarily in abnormal tissue.
Uses include:
• chest pain of unknown cause - with coronary artery narrowing, shows how the narrowing is affecting the heart's blood supply and function.
• to assess improvement in blood supply to heart muscle after bypass surgery or similar procedures.
• to determine prognosis after MI.

Cardiac catheterization - a thin catheter is inserted through an artery or vein, usually in an arm or leg, and advanced into the major vessels and heart chambers. To reach the right side of the heart, the catheter is inserted into a vein; to reach the left side, into an artery.
Uses include:
• measure pressures
• view the inside of blood vessels
• widen a narrowed heart valve
• clear a blocked artery
• obtain blood specimens for metabolic studies
• instill dyes to view blood vessels and heart chambers
• biopsy heart muscle
• sample oxygen and carbon dioxide content of blood in different parts of the heart
• analyze motion of the left ventricle wall and calculate ejection fraction.

A catheter can also be inserted into a vein in the arm or neck and threaded through the right atrium and right ventricle of the heart to the opening of the pulmonary artery. This is pulmonary artery catheterization. Allows blood pressure in the major vessels and heart chambers and the heart's output of blood to the lungs to be measured. Samples of blood can be removed to analyze for oxygen and carbon dioxide content.

Coronary angiography - catheter threaded into an artery in the arm or groin toward the heart and into the coronary arteries. An opaque dye is injected through the catheter into the coronary arteries, and the arteries are seen on a video screen. Cine-angiography provides pictures of the heart chambers and coronary arteries.

Thallium stress test - the same as a treadmill stress test except that a radioactive material, thallium-201, is given intravenously before the exercise ends. Once exercise has stopped, a gamma camera does the thallium imaging. Shows defects where blood flow is reduced and in regions of scarred or infarcted myocardium (e.g., in areas of previous MI). Defects of ischemic myocardium later "fill in," but those due to scarring typically do not. Can also be performed at rest instead of following exercise.

AICD - automatic implantable cardioverter-defibrillator - A pulse generator (about the size of a deck of cards is implanted in the abdomen underneath the skin. Electrodes sense the rhythm of the heart and deliver a powerful shock when a life-threatening rhythm occurs (ventricular tachycardia or fibrillation). If necessary, it can give three to four additional shocks. The batteries are designed to last 4 to 5 years and deliver about 100 shocks. It originally required open-chest surgery for implantation. Now electrodes are inserted into the heart through veins. The pulse generator must be replaced (minor surgery) when batteries die. Firing may cause depression, anxiety, thoughts of dying, etc.

Uses: for people at high risk for sudden death.
• Episodes of ventricular tachycardia
• Those who have survived ventricular fibrillation but have not had an acute heart attack. Are at high risk for another episode of ventricular fibrillation.
• Those with structural defects of the heart, like massive dilation or excessive thickening of the heart muscle.
• After implantation, recovery of normal activity expected in 4 to 6 weeks.

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1. Enclosed is training material that includes both medical information and an explanation of the revised evaluation criteria for intervertebral disc syndrome.

2. A revised examination worksheet for diseases of the spine is also enclosed and should be used immediately (by faxing or mailing to medical facilities when requesting an examination), pending incorporation into the AMIE system. You will be notified when a patch incorporating the revised spine worksheet is made available for installation at medical facilities.

Definition: IVDS is a group of signs and symptoms resulting from displacement of an intervertebral disc or disc fragments at any level of the spine. There are usually pain and other signs and symptoms at or near the site of the disc, and there may be pain referred to more remote areas, plus neurologic abnormalities due to irritation or pressure on adjacent nerves or nerve roots.

Other names: IVDS may also be referred to as slipped, herniated, ruptured, prolapsed, bulging, or protruded disc, degenerative disc disease (DDD), sciatica, discogenic pain syndrome, herniated nucleus pulposus, pinched nerve, etc. There may be some differences, but these terms are not well-defined and are often used interchangeably.

Components: IVDS commonly includes back pain and sciatica (pain along the course of the sciatic nerve) in the case of lumbar disc disease, and neck plus arm or hand pain in the case of cervical disc disease. It may also include scoliosis, paravertebral muscle spasm, limitation of motion of the spine, tenderness over the spine, limitation of straight leg raising, and neurologic findings corresponding to the level of the disc. If the disc compresses the cauda equina (the collection of nerve roots extending from the lower end of the spinal cord), bowel or bladder sphincter functions or sexual function may also be affected.

Frequency of location:
• Lumbar IVDS accounts for 62% of all disc disease.
All but 10% of lumbar IVDS is at the L4-L5 or L5-S1 level.
• Cervical IVDS accounts for 36% of all disc disease.
The C6-C7 level is the most common, and the C5-C6 level the next most common level for cervical IVDS.
• IVDS is uncommon in the thoracic area, where the spine is less mobile.

1. What is the pertinent anatomy for IVDS?

Two anatomic areas are of importance in IVDS: the spine itself and the area(s) innervated by any nerves that are affected due to compression of the nerve roots, spinal nerves, or spinal cord by a displaced disc or disc fragments.
Spine
• The vertebral column is made up of 33 bony vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused into one bone, the sacrum), and 4 coccygeal (fused into one bone, the coccyx).
• The vertebral bodies are separated from one another by intervertebral discs, which are spongy circular cushions made up of cartilage and fibrous tissue. Each disc consists of a tough outer ring called the annulus fibrosis and an inner softer, jelly-like, core called the nucleus pulposus. The upper and lower surfaces of a disc are the cartilaginous endplates.
• Discs, or intervertebral discs, are named according to the number of the vertebrae above and below. Therefore, the disc between the second and third lumbar vertebrae is called the L2-L3 disc, and the disc between the fifth lumbar and first sacral vertebrae is called the L5-S1 disc.

Nerves
• Each segment of the spinal cord gives off a ventral or anterior motor nerve root and a dorsal or posterior sensory nerve root. These two roots join to form a spinal nerve at each segment of the spine. The nerve roots themselves may be damaged by disc disease, but they are particularly vulnerable to pressure from disc disease at the point at which the two roots unite. Irritation or compression of a nerve root by disc disease may lead to pain and other symptoms.

• Nerve root damage from any cause is called radiculopathy. Radiculitis means inflammation of a nerve root and is sometimes used interchangeably with radiculopathy. Radicular refers to the nerve root (or radicle) of a nerve.

• Disc disease may affect either the nerve root that is above the level of the disc or the one below, or both, depending on the site and extent of the disc herniation. This means that an L4-L5 herniated disc, for example, may cause radicular pain and other findings in the area innervated by the L4 spinal nerve, the L5 spinal nerve, or both. Therefore, clinical findings due to IVDS at any given level may vary from individual to individual.

3. What causes IVDS?

With aging, the disc tends to dry out and shrink, causing the annulus fibrosis to deteriorate and bulge outward. This is a bulging disc. With continued degeneration due to mechanical stress, wear and tear, or trauma, the annulus may tear and allow the nucleus pulposus to extrude or rupture through the tear into the spinal canal. This is a ruptured or herniated disc.

With advancing age, degenerative disc disease (DDD) is very common. However, not everyone with DDD is symptomatic. Most symptomatic lumbar disc disease occurs between ages 40-55. Cervical disc disease is more common at an older age. A person who had one disc herniation is at increased risk for another.

Risk factors for IVDS include genetic factors, being a male, having a smoking history, and having a job that involves heavy lifting, bending and twisting into awkward positions, or prolonged whole body vibration. Occupations at risk include long distance truck drivers, soccer players, golf players, and competitive weight lifters.

1. What are the signs and symptoms of IVDS?

The signs and symptoms depend on the level of the spine where the disc is located, the specific location of the disc herniation or protrusion (anterior, posterior, or central), and whether spinal nerve roots, spinal nerves, or the spinal cord are affected.
Although specific nerve roots supply motor branches to certain muscles and sensory branches to certain areas of the skin (or dermatomes), two or more nerve roots may overlap in function.

a. Onset of symptoms varies, but commonly begins either as gradual, progressive back pain; sudden back pain after significant trauma; or back pain after minor trauma.

b. Lumbar IVDS
Pain
• Back pain may be the primary symptom, but pain in the distribution of the irritated or compressed nerve root may also be primary. However, some people have no back pain at all.
• There may also be "referred" pain in the buttocks, sacroiliac joints, and thighs. Referred pain is pain perceived in an area of the body that is far away from the site of pathology.
• May be sciatica, which is sharp, burning, or stabbing pain radiating from the low back down the posterior thigh and posterolateral lower leg, and possibly into the side of the foot. It is due to S1 or L5 radiculopathy.
• Pain is worse when sitting and standing than when lying down, and coughing, sneezing, bending, or heavy lifting may aggravate the pain.

Sensory abnormality - The exact area of numbness or other abnormal sensations, if any, is determined by the particular nerve root affected, and may be in the inner ankle, the great toe, the heel, the outer ankle, the outer leg, or a combination.

Motor abnormality - Weakness or paralysis depends on the particular nerve root affected, and may affect ankle upward or downward motion or dorsiflexion of the great toe on the affected side.

Reflexes - There may be abnormal deep tendon reflexes of knee (patellar) or ankle (Achilles tendon).

Other - There may be bowel or bladder or sexual dysfunction. This is most common with cauda equina syndrome, which is compression of the collection of nerves below the termination of the spinal cord.

Neurological findings - All signs and symptoms not directly in the local area of the back at the disc level, such as motor loss (weakness, paralysis, muscle atrophy), sensory loss (numbness, pain, tingling or other abnormal sensations of the leg or foot), abnormal reflexes, and bowel, bladder, or sexual impairment) represent neurological findings.

Orthopedic findings - Signs and symptoms related to the back at or near the level of the disc, such as pain, tenderness, muscle spasm, limitation of motion, scoliosis, etc., represent orthopedic, but not neurologic, findings.

Common, but not universally present, findings for most frequent levels of lumbar IVDS
• L4-5 IVDS may include pain in posterior or posterolateral thigh radiating to top of foot; weakness of dorsiflexion of the great toe or the ankle; sensory change of great toe, numbness and pain of dorsal surface of lower leg and foot. No reflex abnormalities.

• L5-S1 IVDS may include pain along posterior thigh with radiation to heel, and lateral calf, lateral aspect of foot; weakness or absence of ankle plantar flexion) and eversion of foot; sensory loss of lateral foot and heel; and decreased or absent Achilles (ankle jerk) reflex.

a. Cervical IVDS
Pain
• Neck pain
• Pain radiating down the arm (brachialgia). The pain may be sharp, burning, stinging, or stabbing in the arm, elbow, wrist or fingers, depending on the disc site. It is the upper extremity equivalent of sciatica in the lower extremity.
• May be referred pain in the upper middle of the back.

Sensory abnormality - May be numbness, burning, or weakness in the arm and hand.

Motor abnormality - If there is pressure on the spinal cord, there may be weakness in the legs, shock-like pain down the spine, numbness, or poor coordination.

Other - Headache is common. Cervical problems tend to be less debilitating than lumbar problems.

Common, but not universally present, findings for most frequent levels of cervical IVDS
• C5-C6 IVDS may include weakness of elbow flexion and wrist extension and sensory loss of lateral forearm, thumb, and lateral part of index finger.

• C6-C7 IVDS may include pain in the lateral forearm, thumb, and index finger; weakness of elbow and wrist extension; sensory loss of the long finger; and a decreased triceps reflex.

d. Nerve root tension signs
• Straight leg raising (SLR) test is done by gently lifting the relaxed, extended lower extremity to approximately 90 degrees, with the patient lying supine. This stretches the sciatic nerve and reproduces sciatic pain. The normal limit without pain when there is no sciatic nerve abnormality is between 60 and 120 degrees, depending on the patient's age, habitus, and physical condition. The amount of pain-free flexion is less important than variation between the legs. SLR, while sensitive, is non-specific because it may be limited or painful because of tight hamstring muscles, sacro-iliac joint pathology, or radiculitis.
• Lasegue's sign is worsening of the pain in a SLR test by dorsiflexing the foot.

e. Characteristics of nerve root compression.
• The hallmark is pain. This may be associated with abnormal sensations
(paresthesias) such as tingling or increased sensitivity, or with sensory loss in a dermatomal distribution.
• There may be weakness of muscles innervated by the nerve root.

f. Signs to identify nonorganic back pain that may accompany back problems, and that may indicate the need to consider psychological factors.

Waddell signs are 8 reliable and reproducible signs that suggest nonstructural problems in individuals with back pain. Some patients with physical back problems may have one or two positive Waddell signs on the basis of anxiety or the desire to please the examiner. However, three or more positive signs have a greater predictive value that psychological factors also need to be considered.
• Superficial (skin) tenderness on light palpation.
Positive when the skin is tender to light touch.
• Nonanatomic pain or tenderness
Positive when there is pain or tenderness extending over a wide area involving more than one structure unless there is a reasonable explanation.
• Axial loading that increases pain
Positive if pressing down on the top of the head of a standing patient produces low back pain. It could cause neck pain but should not cause low back pain.
• Rotation
Positive if passive rotation of shoulders and pelvis to 30 degrees in a standing position causes back pain.
• Distracted straight-leg raise
Patient may complain of pain or limitation of motion in a normal SLR test but not when examiner extends the knee with the patient seated, while examining the foot, etc. Such inconsistency is a positive sign.
• Regional sensory change
Positive if does not correspond to a neuroanatomic or dermatomal distribution, e.g., "stocking" or global distribution of numbness.
• Regional weakness
With true muscle weakness, there should be a smooth, non-jerky motion when range of motion is resisted. Positive if there is a sudden letting go of the muscle with "cogwheeling," "give-way," or "breakaway" weakness.
• Overreaction
Positive if there is inconsistent hypersensitivity to light touch or an exaggerated, nonreproducible response, such as excessive grimacing, tremors, etc. But cultural and individual differences, as well as observer bias, must be taken into consideration.

Other
• McBride's test: Patient stands on one leg while raising the opposite knee to the chest. Because the knee is bent, no sciatic stretch occurs, and the spine is flexed, which removes pressure, so this should lessen low back pain. A reported increase in pain, or a refusal to do the test, is a positive sign.
• Burn's test: Patient is asked to kneel on a chair and touch the floor. Since the knees are bent, patients with true back pain or sciatica should be able to do the test without much difficulty. Those with nonorganic back pain usually cannot.

• DTR’s under this scale are considered normal if they are 1+, 2+, or 3+ unless they are asymmetric (not the same on both left and right sides) or there is a dramatic difference between the arms and the legs.
• Reflexes rated as 0, 4+, or 5+ are usually considered abnormal.
• Reinforcement consists of having patients clench their teeth, or for lower extremity reflexes, hook together their flexed fingers and pull apart.

Another DTR rating scale runs from zero to four, with zero being absent, 1 being hypoactive, 2 being normal, 3 being slightly hyperactive, and 4 being maximally hyperactive with clonus.

1. How is IVDS diagnosed?

a. Clinical findings are always a significant factor in diagnosis because neurodiagnostic imaging studies show positive findings in at least one-third of patients who are free of symptoms.
b. X rays: Can demonstrate bony alignment and may show decreased disc height, but do not show a disc fragment compressing a nerve. Have limited value because degenerative changes are age-related and are equally present in asymptomatic and symptomatic persons. However, they help rule out tumors, infections, and fractures.
c. Magnetic Resonance Imaging (MRI): Is the gold standard for visualizing a herniated disc. It can show annular tears and other anatomic details. Does not require an injection.
d. Computed Tomography/ Myelogram (CT Myelogram): A myelogram is an x-ray taken after contrast material is injected into the spinal canal to outline the spinal cord and nerves. Herniated disc fragments or bone spurs compressing the nerves are well visualized but it is inferior to MRI in soft tissue detail. Largely replaced by MRI, which does not require injection.
e. Electromyogram and Nerve Conduction Studies (EMG/NCS): Done in selected cases to assess function of a compressed nerve.
f. Discography: Injection of contrast material directly into a disc. Usually done with CT.

1. How is IVDS treated?

Conservative therapy - the first line of treatment unless there is severe nerve involvement. May include any or all of the following:
• limited bed rest (2-7 days generally, but rarely up to 2 to 4 weeks)
• education on proper body mechanics
• physical therapy, such as ultrasound, heat or ice, massage, conditioning, and exercise programs
• traction
• electric nerve stimulation
• trigger point injections
• weight control
• lumbosacral back support - braces or corsets
• medications, such as analgesics, anti-inflammatory drugs, and muscle relaxants

Most patients recover within four weeks of onset of symptoms, regardless of type of treatment. Sciatica resolves in 75% of patients within six months. When conservative therapy fails (which occurs in about 10%), surgery may be needed.

Common types of surgery
• Laminectomy: traditional surgery performed for lumbar IVDS to relieve pressure on one or more nerve roots. The posterior arch of the spine (lamina) is removed to create more space for the nerve root, in order to relieve compression. Part of the disc may be removed, as may bony spurs and scar tissue.

• Laminotomy: newer, less invasive type of surgery for lumbar IVDS, in which only the small area of the lamina directly surrounding the affected disk, instead of the whole back of the lamina, is removed. This keeps the spine more stable.

• Anterior cervical decompression, with or without fusion: surgery for cervical IVDS, in which the disc material is removed and the spine may be fused at the level of the abnormal disc.

After successful surgery, 80-85% of patients do extremely well and are able to return to work in about six weeks. Small areas of leg numbness may remain. Mild flare-ups of sciatic type pain occasionally develop.

1. How is IVDS rated?

a. IVDS that is primarily disabling because of periods of acute symptoms that require bedrest according to the cumulative amount of time over the course of a year that the patient is incapacitated, i.e., requires bed rest and treatment by a physician, is evaluated at 60 percent if there are incapacitating episodes of at least six weeks total duration during the past 12 months; at 40 percent if there are incapacitating episodes of at least four but less than six weeks total duration during the past 12 months; at 20 percent if there are incapacitating episodes of at least two but less than four weeks total duration during the past 12 months; and at 10 percent if there are incapacitating episodes of at least one but less than two weeks total duration during the past 12 months.

b. IVDS that is disabling primarily because of chronic orthopedic manifestations (e.g., painful muscle spasm or limitation of motion), chronic neurologic manifestations (e.g., footdrop, muscle weakness or atrophy, or sensory loss), or a combination of both, is evaluated by assigning separate evaluations for the orthopedic and neurologic manifestations, using diagnostic code 5293 hyphenated with the appropriate orthopedic (musculoskeletal) or neurologic code.

c. When IVDS is disabling both because of incapacitating episodes and persistent orthopedic or neurologic manifestations, whichever alternative method of evaluation results in a higher evaluation is used.

d. The great majority of cases will be more favorably evaluated under the method in "b".

e. To determine which method results in the higher evaluation:
• Calculate the percentage evaluation based on the cumulative amount of time over the course of the past 12 months that the patient is incapacitated, and combine with the evaluation for all other service-connected disabilities.
• Calculate the percentage evaluation based on the orthopedic and neurologic manifestations, and combine with the evaluation for all other service-connected disabilities.
• Compare the two overall evaluations, and assign an evaluation for IVDS based on the method that results in the higher evaluation.

f. Sciatic nerve functions.
• Made up of nerve roots L4, L5, S1, S2, and S3.
• Supplies the muscles of the back of the knee and lower leg and sensation to the back of the thigh, part of the lower leg, and the sole of the foot.
• Incomplete damage may appear identical to damage to one of its branches (tibial or common peroneal nerve).
• Sensory abnormalities may include sensory changes of the back of the calf or the sole of the foot, such as numbness, tingling, burning, pins and needles sensation, other abnormal sensations, and any level of pain up to excruciating pain.
• Motor loss may include weakness of the knee or foot leading to difficulty walking, weakness or loss of knee flexion, and weakness or loss of foot inversion and plantar flexion.
• Reflexes may be abnormal, with weak or absent ankle-jerk reflex.

g. Common peroneal nerve functions:
• Derived from nerve roots L4, L5, S1, and S2.
• Sensory abnormalities may be loss of sensation, numbness, or tingling of the anterolateral lower leg and dorsum of foot & toes.
• Motor loss may include weakness or loss of dorsiflexion and eversion of foot, loss of extension of toes, and possibly footdrop.

h. When selecting which code to use in a particular case of lumbar IVDS, note that common peroneal nerve function is limited to the lower leg and foot, while the sciatic nerve can affect the knee and even higher areas of the leg. Remember that sensory loss only should be rated at the mild, or at most, the moderate degree of peripheral nerve paralysis (See 38 CFR 4.124a in the paragraph introducing "Diseases of the Peripheral Nerves".)

1. How do the new evaluation criteria for IVDS compare to the old ones?

The former evaluation criteria for IVDS (DC 5293) included a 60-percent evaluation for persistent sciatic neuropathy or other neurologic findings, with little intermittent relief; a 40-percent evaluation for severe recurring attacks; a 20-percent evaluation for moderate recurring attacks; a 10-percent evaluation for a mild condition; and a zero-percent evaluation for the postoperative, cured condition.

These required a subjective determination as to whether the condition is "mild," "moderate," or "severe" and raised questions as to when a 60-percent evaluation was warranted on the basis of neurologic manifestations. There was also uncertainty about whether IVDS with neurologic manifestations could be evaluated higher or lower than 60 percent. This subjectivity has been removed.

Alternative criteria allow evaluation under the method most beneficial to the veteran, and the revised criteria can all be applied to either the pre-operative or post-operative state.

2. What are some problems related to examinations for IVDS?

Unless done by an orthopedic or neurologic specialist, examinations for IVDS have often been less than adequate, but nonetheless have been accepted for rating purposes. The neurological component of the examination (assessing motor loss, sensory loss, and reflexes) in particular has often been incomplete or lacking. However, it is not necessary for rating purposes that all examinations for IVDS be conducted by a specialist.

A revised spine examination worksheet is included with this letter. Note the detailed information and examination findings that it calls for.

3. Is there a revised spine examination worksheet?

A revised examination worksheet for the spine is included with this letter. It is now being programmed into AMIE. Until that is completed, you should fax the revised worksheet to examiners.

4. What are some problems related to rating IVDS?

a. Some raters seem unaware of what the possible neurological findings in IVDS are.

Example: A veteran was evaluated at 40% for lumbar IVDS. A reexamination showed decreased sensation of the arch of the foot and decreased strength of plantar flexion and dorsiflexion of the foot. The rating continued 40% "in the absence of neurological findings". However, decreased sensation of the foot and muscle weakness of the foot are both neurological abnormalities, and the rating should have taken that into account.

In the same case, a later examination showed deep tendon reflexes, motor strength, and sensation normal (meaning there were no longer any abnormal neurological findings). The diagnosis was osteoarthritis with chronic pain syndrome. However, the rating following that examination erroneously increased the evaluation to 60% because "there were findings of neurological pathology".

This letter discusses many neurological findings that may be seen with IVDS at various levels. In general, neurological abnormalities consist of:
• motor abnormalities, such as muscle weakness, paralysis, and atrophy;
• sensory abnormalities, such as numbness, tingling, and pain (in areas other than the area of the neck or back at or near the disc site)
• abnormal reflexes, depending on the site of the IVDS.
• SLR and Lasegue’s sign may confirm sciatic nerve involvement.

b. Raters do not always insist on an adequate examination.

Example: One veteran was suspected by the examiner of malingering. An inadequate examination, which was the only examination of record, was performed. It did not include any of the tests described under #4d or f. Nevertheless, the veteran was assigned 60%.

Example: WWII POW had DDD diagnosis. Examination showed lumbar spine flexion of 60 degrees, left and right bending of 20 degrees. Neurological examination was called "grossly normal". However, a separate examination for cold injury residuals found sensory and motor neuropathy of lower extremities. This discrepancy called for reconciliation of the strikingly different neurologic findings, and an opinion as to whether the findings are all due to cold injury or whether any may be due to DDD, but this was not requested. DDD was rated at 40% without further examination.

c. Overevaluations

Some raters have overevaluated IVDS by assigning 60% under diagnostic code 5293 and a separate 40% or 60% for sciatic or common peroneal nerve dysfunction based in part on the same signs and symptoms. This represents pyramiding (per § 4.14), since some of the same signs and symptoms (leg or foot weakness or sensory loss) were used to support two separate evaluations. The revised evaluation criteria, where the (orthopedic) neck or back problems and the (neurologic) sensory or motor abnormalities remote from the disc site are evaluated separately should eliminate this problem.

Example: Vietnam veteran had low back pain radiating down his right leg. He had 2 back surgeries but had recurrence of the same pain. He was rated at 40%. Later, the evaluation for the back was increased to 60%, and 40% was assigned for peripheral neuropathy of each leg based on an exam that showed lumbar flexion to 40 degrees, right and left lateral flexion to 15, and extension to 15; 50% decrease in sensation (pinprick and light touch) from knees to toes; and motor strength of both legs of 4+/5. 40% for each leg seems appropriate for the neuropathy, but the same findings can not also be used to support an increase under 5293. The leg pain, weakness, and sensory changes should be used to support the evaluation of one or the other, but not both.

Example: DDD was diagnosed in service. One year later, the veteran was rated at 60% following post op surgery for DDD at 2 levels. After an auto accident many years later, the rating was increased to 60% for the back, 60% for the bladder, and 60% for footdrop (under 8520). This veteran declined to leave his wheelchair for the exam, so his back was not actually examined. There seems no justification to continue the 60% evaluation for the back and add 60% for the leg without an adequate examination. This represents both pyramiding and failure to require an adequate examination.

12.What are some important rating points under the revised evaluation criteria?

• First, the alternative methods of evaluation must always be considered and the method more favorable to the veteran (after combining all evaluations for SC conditions) applied.

• Second, insisting upon a comprehensive and adequate examination that follows the examination worksheet guidelines and includes assessments of both the back or neck area and a neurologic assessment of affected extremities (and other areas, such as bladder, when indicated) is the best way to assure that an evaluation accurately reflects the veteran's disability. Accepting an examination that is less than complete may shortchange the veteran and make the evaluation inaccurate.

• Third, the neurologic and orthopedic evaluation criteria used must be carefully selected to make sure they are the most appropriate. (Both the neurologic and spine sections of the rating schedule are in the process of being revised, so the available evaluation criteria will be changing.)

Example: Veteran was diagnosed with L4-L5 IVDS in service based on an MRI. His initial post-service examination noted history of intermittent, but severe, sharp low back pain with radiation down the back of the left leg and more persistent milder low back pain. He had also noted some left foot burning and numbness. His records documented 12 days of prescribed bedrest and treatment for his back during the past 12 months.

On examination he had 75 degrees of forward flexion of the lumbar spine, 30 degrees of extension, 25 degrees of left and right rotation, and 25 degrees of left and right lateral flexion. He had tenderness to deep palpation at the L4-L5 level and slight paraspinous muscle spasm in the lower lumbar area. His deep tendon reflexes showed 1+ ankle reflex on the left and 2+ on the right. He had mild weakness of dorsiflexion of the left great toe and numbness of the great toe and part of the top of the foot. His gait was essentially normal. His SLR test was positive at 40 degrees on the left and at 60 degrees on the right. Lasegue’s sign was positive on the left but negative on the right. The examiner estimated, based on the veteran’s history, that back motion was essentially lost during the periods when bedrest was required, because of pain and muscle spasm. The veteran said the acute episodes of back and leg pain appeared suddenly and eased off after 2 to 3 days of bedrest, analgesics, and muscle relaxants. The diagnosis was IVDS at L4-L5 with left sciatic neuropathy. He was also service-connected for arteriosclerotic heart disease evaluated at 30%, bilateral hearing loss evaluated at 20%, and a tender scar on his right arm evaluated at 10%.

Evaluating on the basis of incapacitating episodes, the evaluation would be 10% (12 days is at least one week but less than two weeks during the past 12 months). Combining that with the evaluations for other conditions would result in a combined evaluation of 60%.

Separately evaluating the orthopedic and neurologic manifestations, the limitation of motion of the back is currently mild, but since he has had several episodes during the past year when the pain was severe, and limitation of motion was estimated to be severe during those episodes, a 20% evaluation would be more appropriate. His neurological problems of sciatic pain, mild toe weakness, and minor sensory loss of the toe and foot represent moderate, incomplete paralysis of the sciatic nerve (8520), for a 20% evaluation. Combining these 2 evaluations with his other SC conditions combines to 70%.

Most beneficial evaluation: Therefore, in this case, as will be true in the majority of cases, separately evaluating the chronic orthopedic and neurological evaluations is the method most beneficial to the veteran, and should be the basis of evaluation.

C. Physical Examination (Objective Findings):
Address each of the following as appropriate to the condition being examined and fully describe current findings:
1. Inspection: spine, limbs, posture and gait, position of the head, curvatures of the spine, symmetry in appearance, symmetry and rhythm of spinal motion.
2. Range of motion
a. Using a goniometer, measure the range of motion, and show each measured range of motion (flexion, extension, etc.) separately rather than as a continuum. Measure active range of motion, and passive range of motion if active range of motion is not normal.
b. State the normal range of motion when providing spine range of motion. For example, state forward flexion of the lumbar spine is 80 out of 90 degrees, and backward extension is 20 out of 35 degrees. (See Chapter 11 of Clinician's Guide for more detailed discussion of spine range of motion.)
c. If the range of motion is affected by factors other than spinal injury or disease, such as the claimant's body habitus, provide an estimated normal range of motion for that particular individual.
d. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.
e. State to what extent (if any), expressed in degrees if possible, the range of motion is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. If more than one of these is present, state, if possible, which has the major functional impact.
1. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.
2. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of back.
3. Neurological examination
a. Sensory examination, to include sacral segments.
b. Motor examination (atrophy, circumferential measurements, tone, and strength).
c. Reflexes (deep tendon, cutaneous, and pathologic).
d. Rectal examination (sensation, tone, volitional control, and reflexes).
e. Lasegue's sign.
f. If the neurologic effects are not encompassed by this part of the examination (e.g., if there are bladder problems), follow appropriate worksheet for the body system affected.
1. For vertebral fractures, report the percentage of loss of height, if any, of the vertebral body.
2. Non-organic physical signs (e.g., Waddell tests, others).

D. For intervertebral disc syndrome
1. Conduct and report a separate history and physical examination for each segment of the spine (cervical, thoracic, lumbar) affected by disc disease.
2. Conduct a complete history and physical examination of each affected spinal segment, whether or not there has been surgery, as described above under B and C.
3. Conduct a thorough neurologic history and examination, as described in C5, of all areas innervated by each affected spinal segment. Specify the peripheral nerve(s) affected. Include an evaluation of effects, if any, on bowel or bladder functioning.
4. Describe as precisely as possible, in number of days, the duration of each incapacitating episode during the past 12-month period. An incapacitating episode, for disability evaluation purposes, is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

Benefits granted under the VA rating schedule are intended to compensate veterans for the average impairment in earning capacity that results from service-connected disease or injury. IU is a special additional benefit to address the truly unique disability picture of a veteran who is unemployable due to service-connected disability, but for whom the application of the rating schedule does not fully reflect the veteran’s level of impairment. An award of IU allows the veteran to receive compensation at a rate equivalent to that of a 100 percent schedular award. However, this benefit is not intended, by regulation or policy, to be a quasi-automatic benefit granted whenever a veteran has met a qualifying schedular evaluation or reached an advanced age.
When raised as an issue, IU is appropriate only in exceptional cases. First determine if the veteran’s disability(ies) warrant a 100 percent schedular evaluation before considering whether to assign a total disability rating under either 38 CFR 4.16 or 3.321.

1. General Requirements for Entitlement to IU
Entitlement to IU requires that the veteran meet certain initial criteria listed at 38 CFR 4.16 as well as continuing criteria as explained below. The IU benefit continues only as long as the veteran remains unemployable. VA monitors the employment status of IU beneficiaries and requires that they submit an annual certification of unemployability.
Consideration for IU requires that:
o The veteran has service-connected disability(ies) as described in 38 CFR 4.16(a) or 4.16(b), and
 The evidence shows unemployability due to a service-connected disability.

1.a. Schedular Requirements
The qualifying schedular evaluations are provided at § 4.16(a). The veteran must be service connected for a single disability evaluated at least 60 percent disabling or service connected for multiple disabilities evaluated at least 70 percent disabling, with one of the multiple disabilities rated at least 40 percent disabling. This section also provides a list of circumstances where the requirement for a single 60 or 40 percent disability may be met by a combination of disabilities that can be considered a single disability (such as those arising from common etiology or a single accident, or those affecting a single body system, etc.).

Careful consideration must also be given to the cause of the veteran’s unemployability.

Unemployability must result from one or more service-connected disabilities. Disabilities for which service connection has not been granted do not qualify for consideration as a source of unemployability.

If the veteran does not meet the requirements of 38 CFR 4.16(a) but there is evidence of unemployability due to a service-connected disability, then the case should be submitted to the Director of Compensation and Pension Service for a determination of eligibility, as provided at 38 CFR 3.321(b) and 4.16(b).

1.b. Unemployability
Unemployability means the inability of a veteran to secure or follow a substantially gainful occupation. A finding of unemployability cannot be made if the evidence shows that the veteran is engaged in, or is capable of being engaged in, a substantially gainful occupation. However, a finding could be made if the evidence shows marginal employment. Marginal employment is defined in terms of a veteran’s earned annual income. This income should generally not exceed the government’s established poverty threshold for one person. Exceeding this threshold may indicate a substantially gainful occupation, as noted by the Court of Appeals for Veteran’s Claims (CAVC) in Faust v. West, 13 Vet.App. 342 (2000), where a substantially gainful occupation was defined as "one that provides annual income that exceeds the poverty threshold for one person."
In addition to the income criterion, evidence showing that employment is marginal rather than substantially gainful may also exist on a "facts found" basis. Examples of this marginal status include employment in the protected environment of a family business or sheltered workshop. Such fact-based marginal employment is consistent with a finding of unemployability.

1.c. Age Factor
It is clear from 38 CFR 4.19 that consideration of a veteran’s age is appropriate when evaluating disabilities for pension claims, but not for awarding IU benefits. The regulation states that unemployability associated with advancing age may not be used as a basis for a total disability rating in service-connected claims. This provision is echoed at 38 CFR 3.341, which states that the service-connected disability must be sufficient to produce unemployability without regard to advancing age.

Advancing age in this context may relate to voluntary retirement or removal from the work force based on tenure or longevity rather than disability. Voluntary retirement does not necessarily show unemployability and should not be used as the only evidence of unemployability. Therefore, when evaluating a claim for IU received from a retired veteran of advanced age, careful consideration must be given to distinguishing a worsened disability that would have caused unemployability from unemployment due to retirement. When an IU claim is received from a veteran of advanced age, the rating should discuss the factor of age and provide an explanation of how the available evidence was evaluated to arrive at the decision to grant or deny IU.

2. Claims for IU
Claims for IU are generally submitted by the veteran but may also be reasonably raised by the evidence of record, including statements or evidence submitted by the veteran indicating unemployability. IU claims filed by the veteran can be considered as claims for an increased evaluation when associated with evidence of a worsened service-connected condition. Claims for an increased evaluation, even without a specific IU claim from the veteran, may give rise to a claim for IU that must be considered.

2.a. Reasonably Raised or Informal Claims
In Norris v. West, 12 Vet.App. 413 (1999), the Court held that where the rating activity is considering a claim for increased evaluation from a veteran who meets the qualifying schedular disability percentage requirements and there is evidence in the claims folder, or under VA control, which shows unemployability due to service-connected disability, then a rating for the claimed increase must also include a rating of a reasonably raised claim for IU. Thus, under the proper circumstances, a claim for IU exists, even though the veteran did not specifically make the claim.

The issue of a reasonably raised claim for IU was also addressed in the Federal Circuit case of Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In that case, the Court held that once a veteran submits evidence of a medical disability, makes a claim for the highest possible rating, and submits evidence of unemployability, the requirement of 38 CFR 3.155(a) that a claimant must "identify the benefit sought" is met. In such cases, VA must consider total disability based upon IU. The Court noted that, under these circumstances, the IU benefit being sought has been identified in conformity with the informal claim requirements of § 3.155(a). (See also, Servello v. Derwinski, 3 Vet.App. 196, 199 (1992) (veteran must provide evidence of entitlement to IU rating by virtue of unemployability)). The Court further stated that VA is obligated to develop a claim "to its optimum," which means considering all potential claims raised by the evidence and applying all relevant laws and regulations, regardless of whether the claim is specifically labeled as a claim for IU. Under circumstances where these conditions apply, but where the veteran does not meet the schedular requirements of § 4.16(a), the case should be referred for extra-schedular consideration as specified at § 4.16(b).

When the veteran has already been awarded a 100 percent total evaluation for one disability, an award of IU for a separate disability or disabilities should not be considered. The VA Office of General Counsel held in VAOPGCPREC 6-99, that when a schedular total disability grant has already been made, no additional monetary benefit would be available to a veteran based on unemployability and any such claim would be moot.

2.b. Claim for IU Defined

• A formal claim for IU on VA Form 21-8940.

• Any written communication indicating that the veteran is unable to work because of his or her service-connected disability(ies).

• To raise an informal IU claim, the veteran must claim an increased evaluation for his or her service-connected disability(ies), submit medical evidence or be shown on VA examination to meet the requirements of § 4.16, and claim the inability to work due to his or her service-connected disability.

• Although a claimant who seeks an increased rating is presumed to be seeking the highest rating possible, a claim for IU cannot reasonably be raised unless the veteran claims to be unable to maintain substantially gainful employment due to service-connected disability.

3. IU Claim Development
3.a. VA Forms 21-8940 and 21-4192

Claims for IU require that a VA Form (VAF) 21-8940, Veteran’s Application for Increased Evaluation Based on Unemployability, be completed and submitted to the VA regional office by the veteran. If an IU claim has been reasonably raised by the evidence of record, a VAF 21-8940 must be sent to the veteran for completion and return before an award can be considered. The VAF 21-8940 requires that the veteran list all employment for the five years prior to becoming too disabled to work and provide an accounting of current income. If the VAF 21-8940 is not returned by the veteran within 60 days, a formal rating decision will be made on the basis of the evidence of record, which considers, among other factors, that necessary evidence was not furnished by the claimant. If the VAF 21-8940 is returned after the rating decision is issued, but within one year of the date sent, the claim should be re-rated. See also section 4.d., Effective Dates for Reasonably Raised IU Claims.

Once the regional office receives VAF 21-8940 and former employers are identified, then VAF 21-4192, Request for Employment Information in Connection with Claim for Disability Benefit, will be forwarded to the former employers listed on the form. The VAF 21-4192 requests that the employer provide information about the veteran’s job duties, on-the-job concessions, date of and reason for job termination, etc. Information given on both VAF 21-8940 and VAF 21-4192 is essential to a fair evaluation of the IU claim. However, IU benefits should not be denied solely because an employer failed to respond to VAF 21-4192.

3.b. Medical Evidence
The available medical evidence must show that a service-connected physical or mental condition is currently so severe and disabling that it prevents the veteran from securing or following a substantially gainful occupation. Any relevant medical evidence must be obtained from both VA and private sources as part of the development and evaluation process. These documents may contain descriptions of physical limitations caused by a service-connected disability or may contain opinions by medical professionals regarding the veteran’s ability or inability to engage in work-related activity. If the evidence obtained is incomplete or inconsistent and does not provide a basis for assessing unemployability, then a VA examination should be scheduled, as provided under 38 CFR 3.326 and 3.159(c)(4). The medical examiner should be requested to provide an opinion regarding the effect of the service-connected disabilities on the veteran’s ability to engage in substantially gainful employment. Further, because it is preferable to rate a veteran as 100 percent disabled on a schedular basis as opposed to awarding IU, order an examination for each service-connected condition that is not at the maximum schedular evaluation.

3.c. Vocational Rehabilitation and Employment Service (VR&E) Records
When the veteran’s claims folder indicates that he or she has been seen by VR&E Service, any records related to this contact must be obtained and evaluated. The records may document the veteran’s participation in a training program or may show that training was not feasible or was unsuccessful. The VR&E records provide important evidence for evaluating current unemployability. VA recognizes the importance of fostering a return-to-work attitude among veterans awarded IU and has implemented the use of a "motivational letter" encouraging new IU recipients to contact VR&E for assistance in returning to work.

3.d. Social Security Administration (SSA) Records
When the claims folder indicates that the veteran has been examined or awarded disability benefits by SSA, any relevant records must be obtained and evaluated. The CAVC held in Murincsak v. Derwinski, 2 Vet.App. 362 (1992), that VA’s duty to assist includes requesting both the SSA decision granting or denying benefits and any supporting medical records. Although VA is not obligated to follow a determination made by SSA, these records may be relevant to the issue of the level of impairment of the veteran’s service-connected disability. However, remember that SSA benefits may be awarded for any disability, whereas IU benefits must be based on service-connected disability. Therefore, careful attention must be paid to determining what disability resulted in a SSA benefit award and whether that disability is one for which service connection has been granted.

4. Rating Considerations
Rating decisions granting or denying entitlement to IU must provide enough explanation so that the claimant and representative can understand the reasons and bases for the decision. As with any decision, the rating must list the evidence considered, a clear explanation of the basis of the decision, and an explanation of the effective date of entitlement.

4.a. Date of Claim
A veteran’s initial claim for IU may be received from any source indicating the benefit being sought, including a VAF 21-4138, Statement in Support of Claim. If the veteran files an informal claim, the regional office must send the veteran a VAF 21-8940 with instructions to complete and return it within one year in order to preserve date of receipt of the earlier communication as the date of claim. If the VAF 21-8940 is received after the one-year period has expired, the date of claim will be the date of receipt of the VAF 21-8940 as provided in § 3.159(b)(1).

If the veteran submits a VAF 21-8940 as the initial IU claim, receipt of this form will represent a claim for IU and will establish the date of claim.

4.b. Effective Dates for IU Awards - Application of 38 CFR 3.400(o)(2)
When an IU claim is associated with a veteran’s worsened service-connected disability, it is considered a claim for increase and the effective date of entitlement must be in accordance with § 3.400(o)(2). That section specifies that the effective date for an increase will be the earliest date that it is "factually ascertainable" that an increase occurred, provided this date is within one year preceding receipt of the claim. Otherwise, the effective date is the date of receipt of the claim.

Claims for an increased rating are considered claims for IU if any of the following conditions apply:
o The IU claim is submitted on VAF 21-8940, or

o In addition to a formal or informal claim for an increased rating, the veteran alleges that he or she is unemployable or VA receives evidence of unemployability, or

o In the course of developing a claim for an increased rating, VA obtains evidence of unemployability and VA grants the veteran a rating that makes the veteran eligible for IU.
When a veteran claims entitlement to IU without claiming increased disability, but increased disability is shown on VA examination or other medical evidence, the effective date of both grants is controlled by 38 CFR 3.400(o)(2).

4.c. Application of 38 CFR 3.400(o)
There are cases, however, where a claim for IU is not associated with a claim for increased disability. In these situations, the effective date is governed by § 3.400(o), which provides that the effective date will be the date of receipt of claim or the date entitlement arose, whichever is later. A case such as this might occur where a veteran has been unemployable due to service-connected disability meeting the schedular requirements for IU, but has never applied for IU. When the veteran files a claim for IU, and there is no associated worsened disability, it is not a claim for an increased disability. Therefore, the date of claim would generally be the effective date, unless evidence indicated a date of entitlement later than the date of claim.

4.d. Effective Dates for Reasonably Raised IU Claims
Reasonably raised claims for IU may arise in a veteran’s original claim or claim for an increased rating. In original claims, IU must be considered when there is evidence of unemployability due to the claimed service-connected disability or disabilities. In claims for an increased evaluation, the CAVC holding in Norris requires that VA must consider a claim for IU when a veteran:
o has submitted a claim for an increased evaluation, and

o meets the minimum schedular requirements for IU, and

o there is evidence of unemployability resulting from service-connected disability.
In addition, if VA receives, or is in possession of, evidence showing a worsened service-connected disability based on a report of medical examination or hospitalization, that evidence may establish an informal claim for increased evaluation, as provided in 38 CFR 3.157. In that event, if the schedular requirements for IU are met, evaluation of the informal claim for increase must also include an evaluation of a reasonably raised claim for IU.

When a claim for IU is reasonably raised, VAF 21-8940 must be sent to the veteran for completion and return. Because this type of IU claim arises when there is an associated claim for increase, the effective date of a grant of IU is governed by § 3.400(o)(2). This means that evidence of a factually ascertainable date of unemployability within the year preceding the date of claim may establish the effective date. In many cases, this may be the same date as that for the increase.

If the reasonably raised IU claim is received at the same time as other claims from the veteran and a rating decision is issued on the other claims, defer the IU claim and send the veteran VAF 21-8940. When the form is returned, it can be evaluated along with other evidence and a decision can be made regarding IU.

If the form is not returned within 60 days of mailing, issue a formal rating decision based on the evidence of record. If the VAF 21-8940 is returned after the rating decision is promulgated but within one year of the date the VAF 21-8940 was requested, re-rate the claim using the date of mailing of the form to the veteran as the date of claim. If IU is granted, the effective date of the award would be the date of receipt of the informal claim. If the form is not returned within one year of the date sent, benefits cannot be paid prior to date of receipt of the VAF 21-8940.

4.e. Chapter 35 Benefits: Survivors’ and Dependents’ Educational Assistance
38 U.S.C. Chapter 35 and regulations at 38 CFR 3.807 establish that educational benefits are available for dependents of a veteran who has been awarded a permanent and total service-connected disability. Although the disabling conditions that lead to an award of IU are considered to be total based on unemployability, they are not always permanent. Unemployability may be temporary: for example, where the veteran undergoes VR&E training and is subsequently able to engage in a substantially gainful occupation. The VA Office of General Counsel has acknowledged that an IU award may be temporary. In VAOPGPREC 5-05, it was determined that § 4.16(b) "permits the award of a total disability rating based on temporary (i.e., non-permanent) inability to follow a substantially gainful occupation." Because IU is acknowledged as a benefit that is not necessarily permanent, careful consideration must be given to granting the Chapter 35 educational benefit in association with the IU award. Substantial evidence must show that the veteran’s unemployability status is permanent before the Chapter 35 grant is appropriate.

5. Continuing Requirements for IU Award
5.a. VA Form 21-4140
After the initial IU award has been made, the veteran must submit a VAF 21-4140, Employment Questionnaire, on a yearly basis to certify continuing unemployability. The VAF 21-4140 is required unless the veteran is 70 years of age or older, has been in receipt of IU for a period of 20 or more consecutive years (as provided at 38 CFR 3.951(b)), or has been granted a 100 percent schedular evaluation. The form is sent out annually to the veteran from the Hines Information Technology Center and must be returned to the regional office. It requests that the veteran report any employment for the past 12 months or certify that no employment has occurred during this period. The VAF 21-4140 includes a statement that it must be returned within 60 days or the veteran’s benefits may be reduced. Completion of this form has a major impact on IU benefits in one of three ways, as described below.

VAF 21-4140 returned with no change
If VAF 21-4140 is returned in a timely manner and shows no employment, then IU benefits will continue uninterrupted.

VAF 21-4140 returned showing employment
If VAF 21-4140 is returned in a timely manner and shows that the veteran has engaged in employment, VA must determine if the employment is marginal or substantially gainful employment. If the employment is marginal, then IU benefits will continue uninterrupted. If the employment is substantially gainful, then VA must consider discontinuing the IU benefit. VA regulations at 38 CFR 3.343(c)(1) and (2) provide that actual employability must be shown by clear and convincing evidence before the benefit is discontinued. Neither vocational rehabilitation activities nor other therapeutic or rehabilitative pursuits will be considered evidence of renewed employability unless the veteran’s medical condition shows marked improvement. Additionally, if the evidence shows that the veteran actually is engaged in a substantially gainful occupation, IU cannot be discontinued unless the veteran maintains the gainful occupation for a period of 12 consecutive months.

Once this period of sustained employment has been maintained, the veteran must be provided with due process before the benefit is actually discontinued, as stated at 38 CFR 3.105(e) and 3.501(e)(2). This consists of providing the veteran with a rating which:
o Proposes to discontinue the IU benefit

o Explains the reason for the discontinuance

o States the effective date of the discontinuance, and

o States that the veteran has 60 days to respond with evidence showing why the discontinuance should not take place.
If the veteran responds with evidence, it must be evaluated. If the evidence is insufficient or the veteran does not respond, then the regional office will discontinue the IU benefit and provide the veteran with a final rating decision explaining the decision. The effective date of the discontinuance will be the last day of the month following an additional period of 60 days, which begins from the date the veteran is notified of the final rating decision.

VAF 21-4140 not returned
If VAF 21-4140 is not returned within the 60 days specified on the form, then the regional office must initiate action to discontinue the IU benefit pursuant to 38 CFR 3.652(a). Due process must be provided with a rating decision that proposes to discontinue the IU benefit for failure to return the VAF 21-4140. If a response is not received within 60 days, then the IU benefit will be discontinued and a rating decision will be sent to the veteran providing notice of the discontinuance. The effective date of discontinuance will be the date specified in the rating decision which proposed discontinuance, as described above, or the day following the date of last payment of the IU benefit, as specified at § 3.501(f), whichever is later. The veteran must also be notified that if the form is returned within one year and shows continued unemployability, then the IU benefit may be restored from the date of discontinuance.

5.b. Income Verification Match (IVM) and Field Examinations
The IVM is a method of comparing an IU recipient’s earned income, as reported to VA by other federal agencies, with the earned income limits that define marginal employment. If income reports show significant earned income above the poverty threshold, the regional office must undertake development to determine if the veteran is still unemployable.

Another method of monitoring unemployability status among IU recipients is through the VA Fiduciary Activity. This service conducts field examinations when it has been notified that an IU recipient might be pursuing a substantially gainful occupation. If the field examiner finds evidence of employment or if the veteran is unwilling to cooperate with the examiner, then the examiner will forward this information to the Rating Activity. A decision must then be made as to whether the IU benefit will be discontinued. This determination must take into account the regulatory requirements listed above, including: (1) whether there is actual employability by clear and convincing evidence and (2) whether there has been substantially gainful employment for 12 continuous months. If termination of the IU benefit is appropriate, a rating decision proposing discontinuance must be completed, with notice to the veteran that he or she has 60 days in which to contest the discontinuance. If no evidence or insufficient evidence is received within this period, then a final rating decision must be promulgated with notice to the veteran that the IU benefit will be discontinued on the last day of the month in which the additional 60-day due process period expires. This 60-day period will begin from the date of the notice of the final rating decision, as provided in § 3.105(e).
---------------

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February 4, 2010
Director (00/21) In Reply Refer To: 211A
All VA Regional Offices Training Letter 10-01
SUBJ: Adjudicating Claims Based on Service in the Gulf War and Southwest Asia

Purpose

Compensation and Pension (C&P) Service is providing the following information and guidelines in order to promote regional office awareness, consistency, and fairness in the handling of disability claims from Veterans with service in Southwest Asia.
Background

The United States military presence in Southwest Asia began in 1990 with Operations Desert Shield and Desert Storm. Troops remain in the theater of operations and currently support Operations Enduring Freedom and Iraqi Freedom.

After the initial Operations Desert Shield and Desert Storm, Congress set forth statutory directives, codified at 38 U.S.C. § 1117, upon which the regulations at 38 C.F.R. § 3.317 are based. These laws address a range of chronic disabilities reported by Veterans who served in Southwest Asia that do not correspond to recognized categories of diseases. The directives and regulations defined such disabilities as “undiagnosed illnesses”; however, subsequent amendments to 38 U.S.C. § 1117 expanded the definition of a chronic disability to include certain diagnosed illnesses with inconclusive etiologies.

These statutory and regulatory provisions apply to any Veteran who served in Southwest Asia, even though their establishment arose from Operations Desert Shield and Desert Storm. As such, adjudication of disability claims for certain diagnosed chronic illnesses from Veterans who served in Southwest Asia differs from procedures for other disability claims.

Questions

Questions can be e-mailed to VAVBAWAS/CO/211/ENVIRO.
/s/
Bradley G. Mayes,
Director
Compensation and Pension Service
******************

Adjudicating Claims Based on Service in the Gulf War and in Southwest Asia

I. Introduction

History of Disability Patterns Associated with Gulf War and Southwest Asia Service

The first Gulf War of 1990-1991, sometimes referred to as the Persian Gulf War, resulted in the liberation of Kuwait from the hostile military forces of Iraq. Operations Desert Shield and Desert Storm involved nearly 700,000 United States service personnel. The initial military operation was successful and relatively short-lived, but led to a continuing presence of United States military personnel in Southwest Asia, and ultimately to the current Gulf War’s Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq.

Following cessation of initial Gulf War military operations in 1991, Veterans of this conflict began to report patterns of chronic debilitating medical symptoms. They typically included some combination of chronic headaches, cognitive difficulties, widespread bodily pain, unexplained fatigue, chronic diarrhea, skin rashes, respiratory problems, and other abnormalities. These symptoms did not correspond easily to recognized categories of diseases and presented a problem for health care diagnoses and treatment procedures, as well as for regional office decision makers attempting to adjudicate claims for disability compensation. Because the problem involved a significant percentage of Gulf War Veterans, estimated at 25 percent, the Department of Veterans Affairs (VA) initiated studies seeking to explain these chronic illness patterns.

Numerous scientific studies have been conducted, including a series by the National Academy of Sciences’ Institute of Medicine (IOM) and a recent study by the Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC). The goal of these studies has been to explain disability patterns associated with Gulf War service in terms of the potential health hazards experienced in the Southwest Asian environment. Among the environmental hazards linked to service during the initial Gulf War are: smoke and particles from over 750 Kuwaiti oil well fires; widespread pesticide and insecticide use, including personal flea collars; infectious diseases indigenous to the area, such as leishmaniasis; fumes from solvents and fuels; ingestion of pyridostigmine bromide tablets on a daily basis, as a nerve gas antidote; the combined effect of multiple vaccines administered upon deployment; and inhalation of ultra fine-grain sand particles. Although IOM studies have produced inconclusive results regarding the specific effects of the environmental hazards on Gulf War Veterans’ health, the RAC study indicates that service in Southwest Asia may be associated with disturbances of the brain and central nervous system, including dysfunctions of the autonomic nervous system, neuromuscular system, neuroendocrine system, and sensory systems, as well as the immune system.
Although most studies have focused on the initial Gulf War, information is accumulating that indicates environmental hazards may also be widespread in the current theater of Gulf War operations and may contribute to the disability patterns typically associated with Southwest Asia service.

Gulf War Legislation and Regulations

In 1994, Congress enacted the “Persian Gulf War Veterans’ Benefits Act,” which is codified at 38 U.S.C. § 1117. This legislation sought to promote research on the medical disability patterns associated with Gulf War service and to provide compensation for “disabilities resulting from illnesses that cannot now be diagnosed or defined, and for which other causes cannot be identified.” Through this legislation, the term “undiagnosed illnesses” was introduced and incorporated into VA regulations at 38 C.F.R. § 3.317.

As more research was conducted and more knowledge of the disability patterns associated with Gulf War and Southwest Asia service accumulated, Congress amended § 1117 in 2001 by expanding the associated disabilities to include “medically unexplained chronic multisymptom illnesses.” The Congressional Joint Explanatory Statement accompanying this statutory amendment described the new terminology as “a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities.” This language was subsequently incorporated into the revised VA regulations at § 3.317. The result of this change was to include both “undiagnosed illnesses” and certain “diagnosed illnesses” under the overarching heading of “a qualifying chronic disability.” Examples of qualifying chronic disabilities were identified by Congress and incorporated into VA regulations. These included chronic fatigue syndrome, irritable bowl syndrome, and fibromyalgia.

Although these three chronic disabilities were intended by Congress to serve as examples, the amended regulation indicated that they were the only disability patterns available for consideration as medically unexplained chronic multisymptom illnesses. Because military personnel continue to operate in Southwest Asia and continue to be exposed to potential environmental hazards, including some not experienced during the initial 1990-1991 Gulf war, C&P Service has determined that an adjustment to the regulation is in order. Therefore, § 3.317 will be amended to clarify that the three currently listed medically unexplained chronic multisymptom illnesses are only examples and are not exclusive. This will allow medical examiners more latitude in evaluating disability patterns based on service in Southwest Asia.

II. Adjudication Guidelines for Regional Offices

Qualifying Veterans

Although the initial directives for adjudicating disability patterns associated with Gulf War service were intended to assist Veterans of the 1990-1991 Persian Gulf War, they remain in effect today and must be applied to all veterans with Southwest Asia service. The regulatory definition of a “Persian Gulf Veteran” provided in § 3.317 includes service in a large area of Southwest Asia, but does not include Afghanistan. Considering the importance of current U.S. military operations in Afghanistan and its environmental similarity to all other regions of Southwest Asia, C&P Service has determined that Veterans with service in Afghanistan fall under all laws related to Gulf War and Southwest Asia service. A regulatory amendment to make this official is forthcoming.

Types of Claims Involved

Disability claims based on Gulf War and Southwest Asia service are generally filed directly by the Veteran. Many were filed in the years following the initial 1990-1991 Gulf War and the rate of filing from these Veterans has diminished. However, such filings continue to occur because of the chronic nature of the disability patterns. Additionally, current evidence indicates that environmental hazards similar to those faced during the initial Gulf War, as well as new potential hazards, are faced by troops currently serving in Iraq and Afghanistan. Therefore, regional office personnel must be aware that a variety of disabilities may affect any Veteran with Southwest Asia service. This means that a thorough review of medical evidence associated with claims from these Veterans is necessary to identify any signs and symptoms potentially associated with Southwest Asia service that are not directly claimed.

Threshold Requirements for Service Connection

Veterans with objective indications of a qualifying chronic disability associated with service in Southwest Asia may be service connected only if the disability became manifest during military service in Southwest Asia or to a degree of 10 percent or more, not later than December 31, 2011. This date will likely be extended by Congressional action. In addition, to establish the chronic nature of the disability, it must exist for at least 6 months or exhibit intermittent episodes of improvement and worsening over at least a 6-month period.

Service connection will not be granted if there is affirmative evidence that the qualifying chronic disability:
(1) was not incurred during active military service,
(2) was caused by intervening conditions or events occurring between the Veteran’s last service in Southwest Asia and the onset of the illness, or
(3) is the result of the Veteran’s own willful misconduct or the abuse of alcohol or drugs.

Qualifying Chronic Disabilities Associated with Service in Southwest Asia

Qualifying chronic disabilities include two distinct categories: (1) “undiagnosed illness” and (2) “medically unexplained chronic multisymptom illness.” The first category, by definition, cannot be associated with a diagnosis. However, the second category refers to diagnosed illnesses that are without conclusive pathophysiology or etiology and are characterized by a cluster of signs and symptoms featuring fatigue, pain, disability out of proportion to physical findings, and inconsistent laboratory findings. Examples of unexplained chronic multisymptom illnesses are provided in § 1117. They include, but are not limited to: (1) chronic fatigue syndrome; (2) fibromyalgia; and (3) irritable bowel syndrome. Service connection is appropriate for any of these when diagnosed.

Although medically unexplained chronic multisymptom illnesses may be diagnosed, and are therefore different from undiagnosed illnesses, if the diagnosis is partially understood in terms of etiology or pathophysiology, then it will not be considered medically unexplained. This caveat represents the intention of Congress to exclude from § 1117 certain readily diagnosable illnesses such as diabetes and multiple sclerosis, which are considered to be of partially understood etiology. The issue of whether a Veteran’s particular chronic multisymptom disability pattern is without a conclusive etiology, or represents a disability pattern with a partially understood etiology, must be determined on a case-by case basis and will require a medical opinion.

Development procedures are covered in M21-1MR at Part IV, Subpart ii, Chapter 1, Section E. The procedures are generally the same as those for any disability claimed by the Veteran or reasonably raised by the regional office. However, as stated previously, C&P Service is amending § 3.317 to clarify that chronic fatigue syndrome, irritable bowl syndrome, and fibromyalgia are not the only disability patterns that can be considered as medically unexplained chronic multisymptom illnesses. Therefore, until the amended regulation becomes final, regional office personnel will be required to hold any claim where the medical evidence shows a disability pattern that is not one of the three currently identified. These claims can be held under end product (EP) code 698 until the amended regulation is finalized. Initial development can proceed normally because the determination that a Southwest Asia Veteran’s particular disability pattern is a previously unidentified medically unexplained chronic multisymptom illness cannot be made until after a VA medical examination has been conducted and a medical opinion rendered.

This Training Letter highlights and clarifies the development procedures most closely associated with service in Southwest Asia. They include:
(1) procuring service treatment records, all relevant private medical records, and Gulf War Registry examination results, if applicable;
(2) acquiring relevant non-medical and lay evidence;
(3) verifying service in Southwest Asia;
(4) identifying the specific nature of the disability; and
(5) requesting a VA medical examination.

Special efforts and inquiries may be necessary when procuring medical evidence in these claims because of the difficulties involved with determining whether or not a diagnosis has been established. Also, non-medical and lay statements take on greater importance. Therefore, extended development may be necessary and consideration must be given to evidence such as any time lost from work and any attempts by the Veteran to seek medical treatment for the disability pattern. Consideration must also be given to lay statements describing the Veteran’s disability pattern from persons in a position to know the Veteran. Such statements may constitute probative evidence by describing changes in the Veteran’s appearance, physical abilities, and mental or emotional status.

Rating Procedures

Rating procedures are covered in M21-1MR at Part IV, Subpart ii, Chapter 2, Section D. When service connection is in order, consideration must be given to assigning a diagnostic code that represents the greatest degree of disability. There may be instances where a chronic undiagnosed illness or diagnosed multi-system illness affect distinct body systems. In such a case, a determination should be made that is most consistent with the evidence and most beneficial to the Veteran.

A special hyphenated analogous diagnostic code system has been developed by VA to track disability claims based on Gulf War and Southwest Asia service. The system involves use of two four-digit number sets separated by a hyphen to identify a qualifying chronic disability. The first four-digit number set starts with the numbers “88,” and is followed by the first two numbers of the body system diagnostic code most closely associated with the disability pattern. If, for example, a disability pattern involves the bronchial pulmonary system, which begins its diagnostic code numbers with 66, the first four-digit number set would be 8866. The second four-digit number set would be the actual diagnostic code that most closely describes the Veteran’s disability pattern. In this example, the Veteran may have signs and symptoms resembling bronchial asthma and so diagnostic code 6602 for bronchial asthma would be used.

When the two four-digit number sets are combined, the hyphenated analogous diagnostic code would be 8866-6602. A more detailed explanation of this system is provided in M21-1MR. Once the disability pattern has been associated with a diagnostic code, the criteria in that code should be used to assign a rating percentage based on the level of disability experienced by the Veteran.

This analogous diagnostic code number system has its historical roots in the disabilities that emerged following the 1990-1991 Gulf War. At the time, the associated disabilities were referred to as “undiagnosed illnesses.” The term has remained in common usage despite legislative changes that added diagnosed medically unexplained chronic multisymptom illnesses as a distinct category of qualifying disease. Therefore, regional office personnel must be aware that this number system applies to all qualifying chronic disability claims associated with service in Southwest Asia during the Gulf War, not just those where an undiagnosed illness is involved.

Any claim made directly by a Veteran, or developed by the regional office based on the Veteran’s records, which involves a diagnosed medically unexplained chronic multi-symptom illness must also be rated using this number coding system.

VA Medical Examination Requests

Because of the non-specific etiology of disability patterns, special considerations must be given to the initial evidence associated with these claims and the issue of when to request a VA medical examination. Regarding the issue of establishing a Veteran’s current disability, which generally serves as the basis for requesting the VA examination, one of two scenarios may occur. Either there is evidence that the Veteran has previously sought medical treatment for the disability pattern and has been “diagnosed” with a condition or there is no evidence that the Veteran has previously been medically treated for the disability pattern.

If a Veteran has previously sought treatment for a multi-symptom illness from a private physician, it is not likely that a resulting medical report will describe the Veteran’s disability pattern as an “undiagnosed illness.” Medical personnel in general and physicians in particular are trained to produce a diagnosis as the basis for treatment. Therefore, a “diagnosis” may appear in the Veteran’s private medical report. However, such a diagnosis is not grounds for denying the claim because medically unexplained chronic multi-symptom illnesses are diagnosable. Regional office personnel must consider the nature of the diagnosis and the disability description provided in the medical report. If the diagnosis involves one of the chronic multi-symptom illnesses described in § 3.317, service connection is appropriate and a VA examination may be necessary to determine severity in order to assign a disability rating. Even if the disability pattern differs from one of the identified chronic multi-symptom illnesses, as would be the case with signs and symptoms of certain respiratory conditions, consideration must still be given to requesting a VA examination. In such a case, it is appropriate to proceed with a VA examination to determine if the condition can be characterized as a disability pattern with an inconclusive etiology. It should also be kept in mind that when medical evidence shows a definite diagnosed condition for a Veteran with Southwest Asia service, that diagnosed condition could have been incurred or aggravated during service and would therefore be subject to service connection on a direct basis outside the provisions of § 3.317.

If there is no medical evidence that the Veteran has previously been treated for the disability pattern and the only significant evidence is the Veteran’s lay statement describing the disability pattern, a VA examination is still warranted. Case law from the Court of Appeals for Veterans Claims (CAVC), interpreting 38 CFR § 3.159(c)(4), establishes a relatively low threshold for requesting VA medical examinations. In McLendon v. Nicholson, 20 Vet.App. 79 (2006), the Court identified four criteria that, when met, require VA to provide a medical examination. In summary, they are: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence that a qualifying in-service event occurred, (3) an indication that the disability may be associated with the Veteran’s service, and (4) insufficient competent medical evidence on file for a decision on the claim.

Regarding Gulf War Illness claims and the first criterion, CAVC has repeatedly held that statements describing visible injuries and pain provided by the Veteran serve as competent evidence for the existence of such injuries and pain. In McLendon, the Court specifically stated that the Veteran “is fully competent to testify to any pain he may have suffered.” Therefore, in claims based on service in Southwest Asia, the Veteran’s lay description of the pain or other signs and symptoms of the disability pattern is competent evidence sufficient to establish a current disability or persistent or recurrent symptoms of a disability. Regarding the second criterion, once service in Southwest Asia is verified, occurrence of the qualifying in-service event is established. The third criterion is a low threshold that involves establishing an indication that the disability pattern may be associated with the Veteran’s period of service. This criterion is met by virtue of the Veteran’s service in Southwest Asia and a statement of a current disability pattern, particularly when such a pattern is consistent with those set forth in § 3.317. The final criterion is met when the regional office does not have sufficient evidence on file to generate a rating decision. This would almost always be the case in these claims because the VA medical examination report is the most likely means for determining whether service connection can be granted under § 3.317.

When requesting VA medical examinations, send the claims file to the examiner, specify that the examiner is to conduct a general medical examination and any required specialty examinations, and include the following italicized language with the request.

Upon exam completion, rating personnel should be aware that VA examiners have been provided with the following language along with the examination request. The language identifies four possible disability patterns that may appear in the examination reports. If the examiner has determined the Veteran’s disability pattern to be either (1) an undiagnosed illness or (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, including but not limited to, chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome, then service connection must be granted based on § 3.317. If the examiner has determined the Veteran’s disability pattern to be either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then service connection cannot be granted under § 3.317 and may only be granted if the medical evidence is sufficient to establish service connection on a direct basis.

Notice to Examiners Regarding Gulf-War Related Disability Claims

Examiner,
VA statutes and regulations provide for service connecting certain chronic disability patterns based on exposure to environmental hazards experienced during military service in Southwest Asia. The environmental hazards may have included: exposure to smoke and particles from oil well fires; exposure to pesticides and insecticides; exposure to indigenous infectious diseases; exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide tablets, as a nerve gas antidote; the combined effect of multiple vaccines administered upon deployment; and inhalation of ultra fine-grain sand particles. In addition, there may have been exposure to smoke and particles from military installation “burn pit” fires that incinerated a wide range of toxic waste materials.

The chronic disability patterns associated with these Southwest Asia environmental hazards have two distinct outcomes. One is referred to as “undiagnosed illnesses” and the other as “diagnosed medically unexplained chronic multisymptom illnesses” that are without conclusive pathophysiology or etiology. Examples of these medically unexplained chronic multi-symptom illnesses include, but are not limited to: (1) chronic fatigue syndrome, (2) fibromyalgia, and (3) irritable bowel syndrome. Diseases of “partially explained etiology”, such a diabetes or multiple sclerosis, are not considered by VA to be in the category of medically unexplained chronic multisymptom illnesses.

Please examine and evaluate this Veteran with Southwest Asia service for any chronic disability pattern. Please review the claims file as part of your evaluation and state that it was reviewed. The Veteran has claimed a disability pattern related to (insert symptoms described by Veteran).

If, after examining the Veteran and reviewing the claims file, you determine that the Veteran’s disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion, with supporting rational, as to whether it is “at least as likely as not” that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia

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SUBJ: Environmental Hazards in Iraq, Afghanistan, and Other Military Installations

Purpose

This training letter will serve three main purposes. First, it will inform regional office employees on specific environmental hazard incidents that present potential health risks to service members and Veterans. Second, it provides guidance on handling claims for disabilities potentially resulting from exposure to environmental hazards while on active duty. Third, it provides “fact sheets” that may serve as valuable resources for VA examiners when they conduct Compensation and Pension (C&P) examinations associated with such exposure. The information and guidelines provided will ensure claims are processed in an objective and compassionate manner across all regional offices.

Background

Service members can be exposed to environmental hazards in the course of their military duties, which may result in adverse health effects. Numerous environmental hazards in Iraq, Afghanistan, and other military installations that could potentially present health risks to service members and Veterans have been identified. The hazards discussed in this training letter are as follows:
(1) Large burn pits throughout Iraq, Afghanistan, and Djibouti on the Horn of Africa;
(2) ”particulate matter” in Iraq and Afghanistan;
(3) a large sulfur fire at Mishraq State Sulfur Mine near Mosul, Iraq;
(4) hexavalent chromium exposure at the Qarmat Ali Water Treatment Plant in Basrah, Iraq;
(5) contaminated drinking water at Camp LeJeune, North Carolina; and
(6) pollutants from a waste incinerator near the Naval Air Facility (NAF) at Atsugi, Japan.
It is imperative that regional office personnel are aware of these environmental health hazards and are well-trained to handle disability claims from Veterans based on exposure to them.

General Information: Throughout the current contingency operations in Iraq and Afghanistan (from approximately 2001 to the present), the U.S. Military utilized large burn pits to dispose of waste. Burn pits are located at every location wherein the military has positioned a forward operating base (FOB). This includes the major US military staging base in the country of Djibouti on the Horn of Africa.

Exposure to open burn pits has created significant concern among Veterans and their families. The most widely publicized of these is the burn pit at Joint Base Balad. The air base at Balad, also known as Logistic Support Area (LSA) Anaconda, is located in Northern Iraq approximately 68 kilometers (km) north of Baghdad and 1.5 km from the Tigris River. It occupies a 25-square kilometer site and is home to approximately 25,000 military, civilian, and coalition personnel.

According to the U.S. Army Center for Health Promotion and Preventative Medicine (USACHPPM), the amount of solid waste burned at Balad was estimated at about 2 tons of material per day in the early stages of troop deployment and increasing up to several hundred tons per day.

The Balad burn pit occupies approximately 10 acres. The burned waste products include, but are not limited to: plastics and Styrofoam, metal/aluminum cans, rubber, chemicals (such as, paints, solvents), petroleum and lubricant products, munitions and other unexploded ordnance, wood waste, medical and human waste, and incomplete combustion by-products. Jet fuel is used as the accelerant. The pits do not effectively burn the volume of waste generated, and smoke from the burn pit blows over the Air Base and into living areas. DoD has reported to VA that as of October 2009, the Balad burn pits were shut down and incinerators were installed. Burn pits still operate at many other bases.

DoD has performed air sampling at Joint Base Balad, Iraq and Camp Lemonier, Djibouti. Most of the air samples have not shown individual chemicals that exceed military exposure guidelines. The air sampling performed at Balad and discussed in an unclassified 2008 assessment tested and detected all of the following: (1) Particulate matter; (2) Polycyclic Aromatic Hydrocarbons; (3) Volatile Organic Compounds; and (4) Toxic Organic Halogenated Dioxins and Furans (dioxins). Each of the foregoing is discussed below with the exception of particulate matter, which will be discussed later in this letter.

Polycyclic Aromatic Hydrocarbons. Polycyclic Aromatic Hydrocarbons (PAHs) are a group of over 100 different chemicals that are formed during the incomplete burning of coal, oil and gas, garbage, or other organic substances. Some of the PAHs that were tested for and detected are listed below. These results are from DoD testing at Balad from January through April 2007.

Volatile Organic Compounds. Volatile Organic Compounds (VOCs) are emitted as gases from certain solids or liquids. They include a variety of chemicals, some of which may have short- and long-term adverse health effects. VOCs are emitted by a wide array of products numbering in the thousands. Examples include: paints and lacquers, paint strippers, cleaning supplies, pesticides, building materials and furnishings, office equipment such as copiers and printers, correction fluids and carbonless copy paper, graphics and craft materials including glues and adhesives, permanent markers, and photographic solutions. The following list reveals some of the VOCs that were tested for and detected at Balad. These results are from DoD testing from January through April 2007.

** Acrolein and Hexachlorobutadiene were occasionally detected far above the MEG ratio—once over 1800 percent above the MEG for Acrolein and over 500 percent above the MEG for Hexachlorobutadiene.

Toxic Organic Halogenated Dioxins and Furans. Dioxins are well known to VA because of their association with tactical herbicide use in Vietnam. Below is a list of the dioxins and furans detected at Balad from January through April 2007.

Currently, VA is not able to determine what possible adverse synergistic health effects might be caused by a combination of (1) high levels of particulate matter; (2) numerous Toxic Organic Halogenated Dioxins and Furans; (3) known and unknown Polycyclic Aromatic Hydrocarbons; and (4) known and unknown Volatile Organic Compounds. For example, 22 of the foregoing toxins, not including dioxins and particulate matter, adversely affect the respiratory system; at least 20 affect the skin; at least 12 affect the eyes; and many others affect the liver, kidneys, central nervous system, cardiovascular system, reproductive system, peripheral nervous system, and GI tract. In at least seven of the foregoing toxins (VOCs and PAHs), dermal contact can significantly contribute to overall exposure. Many troops may have also ingested various amounts of these toxins through food sources because of smoke plume dispersion through base facilities.

Because of the widespread nature of the burn pits and the inability of military personnel records to identify all duty locations, the Veteran’s lay statement of burn pit exposure generally will be sufficient to establish the occurrence of such exposure if the Veteran served in Iraq, Afghanistan, or Djibouti. Regional office personnel must also be aware that many Veterans suffering from illnesses such as, respiratory, cardiopulmonary, neurological, autoimmune, and/or skin disorders, may not associate such conditions with burn pit exposure. Such exposure may have been an accepted fact of life inside the theater of operations. Further, if toxin exposure is raised by a Veteran, he or she will generally not be aware of what toxins were released by burn pits. Rating authorities must therefore be prepared to actively review such claims by recognizing potential exposure issues whenever they are reasonably raised by the record and then developing those claims in accordance with instructions herein.

B. Particulate Matter in Iraq, Afghanistan, and Djibouti

General Information: "Particulate matter" (PM) is a complex mixture of extremely small particles and liquid droplets. PM is made up of a number of components, including acids (such as nitrates and sulfates), organic chemicals, metals, and soil or dust particles. Although PM emissions from natural and manmade sources are generally found worldwide, the PM levels in Southwest Asia are naturally higher and may present a health risk to service members.

There are generally two size ranges of particles in the air that are a health concern. These include particles with a diameter less than or equal to 10 microns (PM10) and those with a diameter of 2.5 microns (PM2.5) and smaller. The size of particles is directly linked to their potential for causing health problems, with the smaller particles being considered more harmful. Particles that are 10 micrometers in diameter or smaller are the particles that generally pass through the throat and nose and enter the lungs. Once inhaled, these powder-like particles can affect the heart and lungs and cause serious health effects.

Primary sources of PM in Southwest Asia include dust storms and emissions from local industries. The DoD conducted a year-long sampling survey to characterize the chemistry and mineralogy of the PM at 15 sites in OIF and OEF. These results were published by the Desert Research Institute in 2008 and are being reviewed by the National Academy of Sciences Committee on Toxicology. The widespread existence of burn pits only exacerbates the high concentrations of PM in Iraq and Afghanistan. DoD stated in their 2008 Balad assessment, that emission from burns pits, among other things, “may increase localized concentration of 2.5 micrometer PM and other potentially toxic air pollutants.”

Most studies relate PM exposure data to respiratory and cardiopulmonary health effects in specific susceptible general population subgroups to include young children, the elderly, and especially those with existing asthma or cardiopulmonary disease. Many variables influence the nature and probability of health outcomes. The key variables are the size-fraction and chemical make up of the PM, the concentration levels, the duration of exposures, and various human factors to include age, health status, existing medical conditions, and genetics. These variables combined with scientific data gaps limit the medical community’s ability to estimate health impacts to relatively healthy troops. Another key factor is that most studies have been on older or less healthy groups. Several studies to determine potential health effects/outcomes are currently underway.

DoD collected approximately 60 air samples at Balad from January to April 2007 and assessed for PM. The samples were taken from five different locations around Balad. The heaviest measured concentration of PM was taken in April 2007—the concentration level was 299 ug/m3 of PM10 sized particles. In total, 50 of the 60 samples registered above the military exposure guidelines.

Although a Veteran who is claiming a disability may not specify the source of exposure as PM, employees handling such claims should be aware of PM exposure and its potential health effects. In certain cases, a statement of exposure may be appropriate to include in VA examination/opinion requests. In all cases involving PM exposure and potentially related disabilities, regional office personnel should ensure that the attached fact sheet is included with C&P examination/opinion requests. As C&P Service becomes more aware of the concentration levels of and health outcomes from PM exposure in Iraq and Afghanistan, we will notify regional office personnel accordingly.

C. Sulfur fire at Mishraq State Sulfur Mine near Mosul, Iraq

General Information: On June 24, 2003, a fire ignited at the Mishraq State Sulfur Mine Plant in northern Iraq. The Mishraq Sulfur Mine is the largest sulfur mine in the world. It burned for approximately 3 weeks and caused the release of roughly 42 million pounds of sulfur dioxide (SO2) per day; hydrogen sulfide (H2S) was also released.

Satellite imagery showed the smoke plume direction, length, and opacity varied throughout the timeframe. Field sampling data collected by a preventive medicine detachment and anecdotal reports of odors and irritation suggest levels of SO2/H2S were not solely located in the immediate vicinity of the fire. Levels were found at the Qayyarah Airfield West (Camp Q West), which is 25km to the south and is a major military supply airstrip and the primary area of deployment for the 101st Airborne Division. Satellite imagery also showed northerly movement of the smoke plume reaching approximately 50 km to the north up to the Mosul Airfield area. DoD estimates that several thousand troops were within the 50km radius from the sulfur fire to the Mosul airfield.

A roster of firefighters and support elements that participated in controlling the fire was prepared. It identifies individuals primarily from the 101st Airborne Division – 52nd Engineer Battalion, 326th Engineer Battalion, and 887th Engineer Battalion. C&P Service is in the process of requesting this roster and other reports, risk assessments, etc., from DoD. USACHPPM has stated that it does not have the means to identify specific exposures; and that all exposed persons are not definitely known.

Both sulfur dioxide and hydrogen sulfide are gases that can produce irritation and reddening of the nose and throat, eye irritation/pain, and coughing. At high levels, sulfur dioxide can burn the skin and can cause severe airway obstruction, hypoxemia, pulmonary edema, and even death. Service members involved with suppressing this fire experienced irritation, minor burns, and effects such as blood-tinged nasal mucous. Some have been found to have long-term respiratory conditions such as “constrictive bronchiolitis.”

In early 2007, USACHPPM medical personnel visited Ft. Campbell, Kentucky, which is the U.S. base for the 101st Airborne Division, and learned that from late 2004 through February 2007, 41 soldiers citing exposures to the sulfur fire and reporting unexplained shortness of breath on exertion, had been referred by the Blanchfield Medical Center to a pulmonary specialist at the Vanderbilt Medical Center. As of February 2007, nineteen (19) personnel had an open lung biopsy, and were all diagnosed with constrictive bronchiolitis. Constrictive bronchiolitis is an inflammatory and fibrotic lesion of the terminal bronchioles of the lungs. This diagnosis is very uncommon and has been associated with inhalation exposures, organ transplantation, certain drugs, and collagen vascular disorders. Individuals with this finding typically have shortness of breath on exertion, but may have normal chest X-rays and inconclusive findings on pulmonary function testing. Due to some similarities, symptoms of constrictive bronchiolitis may be wrongly attributed to asthma or chronic obstructive pulmonary disease (COPD).

Regional office personnel may have a difficult time rating disabilities in this population. In most cases, the affected soldiers are comfortable at rest and are able to perform the activities of daily living. They have normal or near normal pulmonary function tests, but, at the same time, become short of breath on slight physical exertion, cannot meet physical training requirements, and are considered unfit for deployment. This unique circumstance challenges those who must determine a disability rating. Pulmonary function testing is the usual standard for rating respiratory disabilities. Therefore, rating authorities should utilize an appropriate analogous code (such as 6600-6604) since the condition does not have its own diagnostic code, and consider extra-scheduler ratings in such cases when there is evidence that a Veteran’s employment is affected.

While individual exposure levels cannot be accurately determined, USACHPPM currently considers constrictive bronchiolitis (initially diagnosed as “bronchiolitis obliterans”) to be plausibly associated with exposure to the 2003 Mishraq State sulfur fire event. This health effect has been scientifically associated with high exposures to SO2 . While personnel exposures varied considerably, individual risk factors or susceptibility may play a role. Due to limitations in the military deployment tracking databases used in 2003-2004, the actual cohort of all exposed persons is not definitively known.

The Veteran’s lay statement of exposure to the sulfur fire is sufficient if his or her service records shows service in Iraq at Mosul Airfield or Qayyarah Airfield West (Camp Q West) at any time during the 4-week period starting from June 24, 2003. Otherwise, verification of exposure should be made on a case-by-case basis with careful consideration given to the period of deployment together with duty locations. Contacting a military unit the Veteran served in at the time of Iraq deployment may be necessary to confirm the required location. C&P Service will notify regional offices if and when it receives the DOD list of personnel involved in this incident. In the meantime, a careful review of service treatment records, personnel records and other alternative evidence such as lay statements should be conducted in efforts to verify exposure. If the claim is for a respiratory condition possibly related to the sulfur fire exposure, consider requesting tests for “bronchiolitis” to be conducted in addition to other respiratory testing, while noting that many standard test results may be normal.

D. Qarmat Ali Water Treatment Plant in Basrah, Iraq

General Information: From approximately April through September of 2003, Army National Guard (NG) personnel from Indiana, West Virginia, South Carolina, and Oregon served at the Qarmat Ali Water Treatment Plant in Basrah, Iraq, and were assigned to guard contract workers who were restoring the plant. During that time, sodium dichromate, a source of hexavalent chromium, which was previously used as a corrosion-preventing chemical by former Iraqi plant workers, was found on the ground and measured in the air. Hexavalent chromium, or Chromium VI (six), in sodium dichromate is a lung carcinogen through inhalation.

Chromium VI is also an acidic compound that can cause immediate irritation to the eyes, nose, sinuses, lungs, and skin. USACHPPM provided a medical evaluation for certain soldiers there at the time, which took place in October 2003. According to USACHPPM, 137 service members were evaluated. The results at the time showed some abnormalities in individuals, such as complaints of eye, nose, throat and/or lung irritation, or abnormal pulmonary function, kidney, or liver tests. However, the Army stated that it could not specifically trace these symptoms to chromium exposure.

C&P Service has also begun researching the list of identifiable service members to determine who has filed claims for disability benefits for any condition potentially related to this toxin exposure. Research is ongoing and is primarily focused on, but not limited to, diseases of the skin and respiratory system. This assessment takes into consideration all identifiable members of the Guard who have previously filed disability claims for such conditions and who have claims currently pending for such conditions. It also assumes that such claims were filed after exposure, but not necessarily expressly related to exposure.

The Veterans Health Administration (VHA) has begun to augment the Gulf War Registry to reflect service at Qarmat Ali. VHA is verifying the numbers of these Veterans who have either enrolled in care or received a Gulf War Registry examination. The involved Guard members who have had an initial examination will be recalled to have a complete exposure assessment as well as a more targeted physical examination and ancillary testing to detect indications of health outcomes that may be related to hexavalent chromium. Those who have yet to enroll in the registry will receive this targeted exam initially, which includes a chest radiograph and pulmonary function test. This evaluation will be repeated periodically.

DoD has confirmed with VA that NG personnel from Indiana, West Virginia, South Carolina, and Oregon served at the Qarmat Ali Water Treatment Plant in Iraq. Therefore, verification of individual exposure is not required for Veterans who served in one of these NG units if their service in Iraq was between April through September 2003.

E. Contaminated drinking water at Camp LeJeune, North Carolina

General Information: From the 1950s through the mid-1980s, persons residing or working at the U.S. Marine Corps Base at Camp Lejeune, North Carolina, were potentially exposed to drinking water contaminated with volatile organic compounds. Two of the eight water treatment facilities supplying water to the base were contaminated with either tricholoroethylene (TCE) or tetrachloroethylene (perchloroethylene, or PCE) from an off-base dry cleaning facility. The Department of Health and Human Services’ Agency for Toxic Substances and Disease Registry (ATSDR) estimated that TCE and PCE drinking water levels exceeded current standards from 1957 to 1987 and represented a public health hazard. The heavily contaminated wells were shut down in February 1985, but it is estimated that over one million individuals, including civilians and children, may have been exposed.

There has been much public interest and media coverage of the potentially harmful health effects associated with the contaminated water supply at Camp Lejeune. The National Research Council of the National Academies of Science released a report in June 2009, which found that scientific evidence for any health problems from past water contamination is limited. The evidence for amounts, types, and locations of contamination were not well recorded at the time and cannot now be extrapolated. Therefore, conclusive proof of harmful health effects is unlikely to be resolved with any further studies.

In October 2008, the Department of the Navy issued a letter to Veterans who were stationed at Camp Lejeune between 1957 and 1987. The letter explained that the Navy had established a health registry and encouraged participation. For further information or to refer Veterans with questions regarding Camp Lejeune, the following websites have been established: http://www.atsdr.cdc.gov/sites/lejeune/index.html or www.marines.mil/clsurvey/index.html. Veterans may also call the Department of the Navy at (877) 261-9782.

Disability claims based on exposure to contaminated water at Camp Lejeune must be handled on a case-by-case basis. Actual service at the installation during the timeframe of water contamination must be established.

F. Waste Incinerator near Naval Air Facility in Atsugi, Japan

General Information: During the years between 1985 and 2001, personnel at NAF Atsugi were exposed to environmental contaminants. The source was an off-base waste incinerator business owned and operated by a private Japanese company. Known as the Jinkanpo or Shinkampo Incinerator Complex, the operation consisted of a combustion waste disposal complex equipped with four incinerators burning up to 90 tons of industrial and medical waste daily. The complex was located approximately 100 yards south of the NAF Atsugi perimeter and during the spring and summer months the prevailing winds would blow the incinerators’ emissions over the NAF. Environmental assessment reports conducted during the years of incinerator operations stated that there was significant degradation of air quality at the sites sampled and identified the sources as incomplete burning of wastes in uncontrolled incinerators and evaporation of solvents poured onto outdoor waste piles prior to incineration. The identified chemicals of potential concern include: chloroform; 1,2-dichloroethane; methylene chloride; trichloroethylene; chromium; dioxins and furans; and other particulate matter.

Since the 1990s, the Navy has informed sailors and their family members about the possible long-term health effects of living at Atsugi. The Navy has also published various health information about Atsugi at the following website:

The above-listed Navy website provides several recent studies of the Atsugi population. The first, a review and report by Battelle did not find sufficient exposures to warrant any additional surveillance testing for former residents of NAF Atsugi. However, this review does not offer conclusive proof that service members who were present between 1985 and 2001 were unaffected by the environmental contaminants. The second is a health study looking at health outcomes of the former residents of NAF Atsugi compared to a similar population assigned to NAF Yokosuka. Differences were found for atopic and contact dermatitis, both more likely in the Atsugi population. ATSDR reviewed Navy’s efforts, and their opinion is noted in a letter provided on the website. This ATSDR review references two additional health outcome studies, respiratory disease and pregnancy outcomes, conducted during the incinerator’s operations. Neither study found an increased risk for the NAF Atsugi residents.

Disability claims based on exposure to environmental airborne contaminants at NAF Atsugi must be handled on a case-by-case basis. Actual service at the installation during the timeframe of environmental contaminants must be established.

2. Claims Processing Policies and Procedures

A. Priority of Processing

Because of the potential of receiving claims due to exposure to environmental hazards from Veterans who served in Iraq and Afghanistan, employees should review VBA Letter 20-07-19 dated February 6, 2009, to determine if “priority processing” procedures apply.

B. End Product Control and Tracking

Upon receipt of service connection claims for disabilities due to exposure to environmental hazards or toxic agents, establish a standard end product, (e.g., 110, 010, 020). A special end product to control these issues is not necessary.

Employees involved in the development of these claims must choose the appropriate Special Issue identifier on the MAP-D Contentions screen. Currently, the only identifier pertaining to exposure claims is “Environmental Hazard in Gulf War,” which is only appropriate for exposure within Southwest Asia. As C&P Service updates corporate applications, (i.e., MAP-D, RBA 2000, etc.) to better track and identify these types of claims, we will notify the field accordingly. Therefore, so as not to dilute future data on hazardous exposure claims regarding Southwest Asia service, do not use the “Environmental Hazard in Gulf War” identifier for claims regarding Atsugi or Camp Lejeune service.

C. Development

By taking the following steps in the development process, raters will be well-equipped to make fair and equitable decisions on service-connection claims as a result of exposures to environmental hazards.

• If Veteran alleges exposure to environmental hazards during service, but does not claim service connection for a specific disability, inform the veteran that he/she must at least identify a symptom or cluster of symptoms since exposure in and of itself is not a disability.

• Ensure the claimant provides at least some general information about the exposure event. A follow-up letter or phone call to the Veteran may be required if the Veteran fails to provide sufficient information regarding exposure and/or disability claimed because of such exposure.

o Notwithstanding the foregoing instructions, regional office personnel must actively review cases for potential exposure. While many service members who served in Iraq and/or Afghanistan may have been exposed, for example to burn pits and particulate matter, not all Veterans will be aware of such exposure or will associate such exposure with specific disabilities.

o Therefore, regional office personnel must be vigilant in reviewing claims from Veterans with Southwest Asia service, especially when the claim is for service connection for disabilities such as respiratory, skin, autoimmune, neurological (except where clearly caused by injury), gastrointestinal disorders, etc. Many Veterans will simply be unaware of the possible link between such disabilities and the exposures discussed in this training letter. In these cases, it may be necessary to invite or solicit a specific claim from the Veteran and undertake the development procedures explained in this training letter.

• Develop for service treatment records and any VA and/or private medical records that are noted by the claimant.

• Verify dates of military service and obtain military personnel records as per normal procedures.

D. Verifying Exposure to Environmental Hazards

Verifying and/or conceding exposure is one of the key elements in the adjudication process. VA is actively working with DoD to identify individuals who were exposed to specific environmental hazards while serving in the military. In most cases, it will not be possible to refer to a list of service members present at a specific location. It is critical that VA employees rely upon all available sources of evidence when verifying and/or conceding exposure.

Currently, C&P Service has only acquired a list for those who served at the Qarmat Ali Water Treatment Plant in Basrah, Iraq. For other incidents, if exposure cannot be verified through an official list provided by DoD, then personnel records should be reviewed for evidence that corroborates the Veteran’s statement of exposure.

IMPORTANT: Service Treatment Records, to include the Post-Deployment Health Assessment (PDHA) and Discharge Examination, should be carefully reviewed for exposure information. The PDHA includes specific questions relating to exposure incidents.

Because military service records will not verify all incidents, if any, of exposure, alternative evidence such as personal statements, buddy statements, unit histories, news articles, or other lay evidence shall be considered in establishing whether the Veteran participated in or was affected by an in-service exposure incident. Exposure may be verified or conceded, if the statements provided by the Veteran and/or others are consistent with the facts, places, and circumstances of the Veteran’s service. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a).

Because of the widespread nature of the burn pits, and the inability of military personnel records to identify all duty locations, the Veteran’s lay statement of burn pit exposure generally will be sufficient to establish the occurrence of such exposure if the Veteran served in Iraq, Afghanistan, or Djibouti. For example, a Veteran who performed guard duty at a burn pit in Iraq would have been subject to potentially higher levels of toxic exposure than someone who did not perform such duty. The Veteran’s service records will generally not provide that level of detail necessary to show that he/she performed that particular duty. Thus, if the statements provided by the Veteran and/or others are consistent with the facts, places, and circumstances of his or her service, then concede them as a fact of record. See Id. (Do not confuse this section with the provisions found at 1154(b)—applicability of 1154(a) does not require evidence of combat).

Further, in applying section 1154(a) to concede a Veteran’s exposure to burn pits and PM specifically, it is important to remember the information contained in section 1.A. and 1.B. of this Training Letter. Essentially, that VA is aware, primarily through cooperation with DoD, of the extent of potentially hazardous exposures (i.e., elevated PM levels throughout Iraq, Afghanistan, and Djibouti; as well as burn pits located at all military FOBs in these same regions). Therefore, VA is aware of the “facts, places, and circumstances” of a Veteran’s service in those regions. Going beyond section 1154(a) by requiring proof of exposure, such as by service personnel or unit records, could arguably violate section 1154(a). The resulting interplay between VA’s knowledge of exposure and section 1154(a), results in easily conceding exposure without an actual “presumption” of exposure.

Note: Because Veterans generally will not possess the type of exposure information contained in this training letter, regional office personnel should be aware of the environmental hazards that may apply for Veteran claimants who served in Iraq, Afghanistan, or Djibouti, even if the claimants did not allege such exposure, (e.g., Particulate Matter exposure). Be aware also that more than one environmental hazard may apply when Veterans are alleging exposure to a specific event. For example, if a Veteran claims a disability due to exposure at the Qarmat Ali Water Treatment Plant, each pertinent Fact Sheet should be provided to VA examiners, as explained below, since the Veteran served in Iraq and could have been exposed to burn pit emissions and the same high levels of particulate matter as others in the Southwest Asia theater of operations.

E. VA Examinations and Medical Opinions

In claims for disability compensation, VA has the responsibility to assist the claimant by obtaining a medical opinion and/or examination when the opinion and/or examination is necessary to make a decision on the claim. 38 CFR 3.159(c)(4)

Reminder: Generally, VA examinations are ordered for all claims received within one year of separation from the military, unless the evidence is sufficient for deciding the claim. This includes a general medical examination and any specialty examinations deemed necessary.

In claims received more than one year after separation from service, a VA examination should be ordered for environmental-hazard claims when the evidence of record contains the following three elements:

• Element 1: Evidence of a current diagnosed disability or persistent or recurrent symptoms of disability.

• A claimant ordinarily lacks the medical training and experience to diagnose his/her own medical condition or offer a medical opinion. However, a claimant is competent to describe symptoms of disability that he/she is experiencing, (e.g., shortness of breath, coughing, fatigue, skin rash, etc.). Therefore, medical evidence of the claimed disability is not necessary to trigger the VA examination request as long as the claimant describes persistent or recurrent symptoms of the claimed disability.

• Element 2: Evidence that the veteran was exposed to an in-service exposure event or incident, including a Veteran’s lay evidence. For the purposes of this element, exposure to certain environmental hazards can be conceded, on a case-by-case basis, as previously discussed.

• See section of training letter on Verifying Exposure to Environmental Hazards

• Element 3: Evidence that the claimed disability or symptoms may be associated with the in-service exposure event.

• In determining whether a claimed condition may be associated with an in-service exposure incident and therefore warrants a VA examination or opinion request, you must consider the information herein to determine if the Veteran’s symptoms may be representative of an illness or disease linked to a specific exposure. Because the scientific studies to identify health effects of exposures are in the preliminary stages, C&P Service is providing general guidelines as to what type of symptoms trigger a VA examination or opinion. If in doubt, regional office personnel should err on the side of the Veteran when determining if a VA examination or opinion is needed. If that doubt exists in any degree, then evidence of a current disability (or symptoms of a disability) is sufficient to request a medical examination and medical nexus opinion if the proper service is verified and no evidence exists of subsequent cause for the disability.

• Regional office personnel should carefully review lay statements that may provide evidence that shows continuity of symptoms from service to the present. In cases where evidence showing continuity of symptoms is strong, medical examinations/opinions may not be necessary. In others, it may serve as evidence that a claimed condition may be associated with an in-service exposure event(s). Ultimately, VA employees should remember that the threshold bar for requesting an examination/opinion is very low, but if existing evidence is satisfactory to decide the claim, then a VA examination is not necessary.

What to Include in a VA Examination or Medical Opinion Request

When requesting medical examinations, inform the examiner of the Veteran’s service along with the location and nature of the environmental hazard in which the Veteran was exposed. When requesting examinations/opinions, always forward the claims file to the medical examiner (or appropriate material to the contract examiner) and direct him or her to review the medical and other evidence in the claims folder and provide a rationale for his or her opinion. Fact Sheets explaining the various environmental hazards are attached to this training letter. The pertinent Fact Sheets must be made available to the VA medical examiner for review. The examiner should state whether it is more likely, less likely, or as likely as not that a Veteran’s claimed condition is related to the hazardous environmental exposure. The fact sheet(s) must subsequently remain in the record.

Note: The Fact Sheets are not meant to influence examiners rendering opinions concerning the etiology of any particular disability, but rather to ensure that such opinions are fully informed based on all known objective facts. It is imperative that examiners utilize this information objectively and together with other evidence, (e.g., lay statements) in the Veteran’s record.

In some cases, an opinion based on record review only may be sufficient. In other cases, a current examination may be required. When an opinion only is initially requested, the examiner should be informed that an examination will be scheduled if the examiner believes it is necessary in order to render the requested medical opinion.

When the opinion is completed and returned to the regional office, rating personnel should ensure that the examiner has identified the specific evidence reviewed and considered when forming the opinion, provided a rationale for the opinion, and stated his/her conclusions using one of the legally recognized phrases.

Ref: M21-1 Part VI, 1.05(b), Exhibit A.

F. Rating Principles

When rating a disability due to an in-service exposure event, it is imperative that raters adhere to the principles relating to service connection set forth in 38 CFR § 3.303. Because scientific studies regarding health effects from exposures are in the preliminary stages, raters should carefully review the nature, dates, and locations of the Veteran’s military service, and apply the law under a broad and liberal manner, consistent with all available facts and circumstances. Claims should be evaluated on a case-by-case basis with evidentiary weight given to medical examinations and opinions from both private and VA physicians. In all cases, the benefit of the doubt shall be given to the Veteran. 38 CFR § 3.102.

Claims based on Southwest Asia Service (38 CFR § 3.317)
Regulations governing claims based on undiagnosed illnesses, and medically unexplained chronic multisymptom illnesses that were promulgated following the initial 1990-1991 Gulf War continue to be in effect for any Veteran with Southwest Asia service. Regional office personnel are reminded that the provisions of 38 CFR § 3.317 should be applied when rating claims for disabilities due to environmental hazards in the Southwest Asia theater, if the following applies:
• The Veteran claims a disability due to an environmental hazard while serving on active military, naval, or air service in the Southwest Asia theater of operations from August 2, 1990, through a date yet to be finally determined;
• The medical evidence reveals an undiagnosed illness, or a diagnosed condition without conclusive etiology; and
• The medical evidence does not provide a sufficient link to Veteran’s military service.
If the above scenario is presented, the claim should be developed under the Gulf War and Southwest Asia service procedures outlined in Training Letter 10-01, released February 4, 2010. (See “What to Include in a VA Examination or Medical Opinion Request” in section 2.E.).

Independent Medical Opinions (§3.328)
If there are complex or controversial medical issues involved in the rating of disabilities claimed as a result of environmental exposures, an advisory opinion can be obtained from non-VA medical experts. Requests for this type of opinion are initiated by the regional office and submitted through the Veterans Service Center Manager to C&P Service for approval. The request must detail the reasons why the opinion is necessary.
Note: These are special requests and not the same as requesting a VA physician to express an opinion on a VA examination.

Large burn pits have been used throughout the operations in Iraq and Afghanistan to dispose of nearly all forms of waste. It is estimated that such pits, some nearly as large as 20 acres, are or have been located at every military forward operating base (FOB). The pit at Joint Base Balad, also known as Logistic Support Area (LSA) Anaconda, has received the most attention. The burned waste products include, but are not limited to: plastics, metal/aluminum cans, rubber, chemicals (such as, paints, solvents), petroleum and lubricant products, munitions and other unexploded ordnance, wood waste, medical and human waste, and incomplete combustion by-products. Jet fuel (JP- is used as the accelerant. The pits do not effectively burn the volume of waste generated, and smoke from the burn pit blows over bases and into living areas.

DoD has performed air sampling at Joint Base Balad, Iraq and Camp Lemonier, Djibouti. Subsequently, DoD has indicated that most of the air samples have not shown individual chemicals that exceed military exposure guidelines (MEG). Nonetheless, DoD further concluded that the confidence level in their risk estimates is low to medium due to lack of specific exposure information, other routes/sources of environmental hazards not identified; and uncertainty regarding the synergistic impact of multiple chemicals present, particularly those affecting the same body organs/systems.

The air sampling performed at Balad and discussed in an unclassified 2008 assessment tested and detected all of the following: (1) Particulate matter (PM-10) (and PM 2.5); (2) Polycyclic Aromatic Hydrocarbons (PAHs); (3) Volatile Organic Compounds (VOCs); and (4) Toxic Organic Halogenated Dioxins and Furans (dioxins). Each of the foregoing is discussed below.

Some of the PAHs that were tested for and detected are listed below. These results are from DoD testing from January through April 2007.

* Acrolein and Hexachlorobutadiene were, although seldomly, detected far above the MEG ratio—once over 1800 percent above the MEG for Acrolein and over 500 percent above the MEG for Hexachlorobutadiene.

Below is a list of the dioxins and furans detected, all reportedly at low doses.

For examination purposes, 22 of the VORs and PAHs, affect the respiratory system; 20 affect the skin; at least 12 affect the eyes; and others affect the liver, kidneys, central nervous system, cardiovascular system, reproductive system, peripheral nervous system, and GI tract. In at least seven, dermal exposure can greatly contribute to overall dosage. Therefore, when considering total potential exposure, please consider the synergistic affect of all combined toxins, primarily through inhalation and dermal exposure, but also through ingestion.

This information is not meant to influence examiners rendering opinions concerning the etiology of any particular disability; but rather to ensure that such opinions are fully informed based on all known objective facts. Therefore, when rendering opinions requested by rating authorities for a disability potentially related to such exposure, please utilize this information objectively and together with the remaining evidence, including lay evidence, in the Veteran’s record.

_____________________
Adjudication Authority

FACT SHEET
Particulate Matter throughout Iraq and Afghanistan

NOTICE TO VA EXAMINERS
VA Considers this Veteran Exposed to High Levels of Particulate Matter

"Particulate matter” (PM), is a complex mixture of extremely small particles and liquid droplets made up of a number of components, including acids (such as nitrates and sulfates), organic chemicals, metals, and soil or dust particles. The PM levels in Southwest Asia are naturally higher than most of the world and may present a health risk to service members. There are two sizes of particles in the air that are a health concern—particles with a 10-micron (PM10) diameter or smaller, and those 2.5 microns (PM2.5) and smaller. The size is directly linked to potential for causing health problems. Once inhaled, 10-micron sized particles or smaller can affect the heart and lungs and cause serious health effects.

Primary sources of PM in Southwest Asia include dust storms and emissions from local industries. The DoD conducted a year-long sampling survey to characterize the chemistry and mineralogy of the PM at 15 sites in OIF and OEF. These results were published by the Desert Research Institute in 2008 and are being reviewed by the National Academy of Sciences Committee on Toxicology. DoD stated in their 2008 Balad assessment, that emission from burns pits, among other things, “may increase localized concentration of 2.5 micrometer PM and other potentially toxic air pollutants.”

Most studies relate PM exposure data to respiratory and cardiopulmonary health effects in specific susceptible general population subgroups to include young children, the elderly, and especially those with existing asthma or cardiopulmonary disease. Many variables influence the probability of health outcomes. The key variables are the size-fraction and chemical make up of the PM, the concentration levels, the duration of exposures, and various human factors to include age, health status, existing medical conditions, and genetics. These variables combined with scientific data gaps limit the medical community’s ability to estimate health impacts to relatively healthy troops. Another key factor is that most studies have been on older or less healthy groups. Several studies to determine potential health effects/outcomes are currently underway.

DoD collected approximately 60 air samples at Balad from January to April 2007 and assessed for PM. The samples were taken from five different locations around Balad. The heaviest measured concentration of PM was taken in April 2007—the concentration level was 299 ug/m3 of PM10 sized particles. In total, 50 of the 60 samples registered above the military exposure guidelines.

This information is not meant to influence examiners rendering opinions concerning the etiology of any particular disability; but rather to ensure that such opinions are fully informed based on all known objective facts. Therefore, when rendering opinions requested by rating authorities for a disability potentially related to such exposure, please utilize this information objectively and together with the remaining evidence, including lay evidence, in the Veteran’s record.

_____________________
Adjudication Authority

FACT SHEET
Sulfur Fire at the Mishraq State Sulfur Mine Near Mosul, Iraq

In June 2003, a fire ignited at the Mishraq State Sulfur Mine in northern Iraq. The sulfur mine is the largest in the world and resulted in the largest manmade sulfur fire in recorded history. It burned for approximately 3 weeks and caused the release of roughly 42 million pounds of sulfur dioxide (SO2) per day; hydrogen sulfide (H2S) was also released.

In early 2007, medical personnel from the U.S. Army Center for Health Promotion and Preventative Medicine visited Ft Campbell, Kentucky, which is the U.S. home base for the 101st Airborne Division. Members of the 101st were firefighters at the Mishraq State Sulfur Mine fire. The medical personnel learned that from late 2004 through February 2007, 41 soldiers, citing exposures to the sulfur fire and reporting unexplained shortness of breath on exertion, had been referred by the Blanchfield Medical Center to a pulmonary specialist at the Vanderbilt Medical Center. As of February 2007, nineteen (19) personnel had an open lung biopsy and were all diagnosed with constrictive bronchiolitis. Constrictive bronchiolitis is an inflammatory and fibrotic lesion of the terminal bronchioles of the lungs. This diagnosis is very uncommon and has been associated with inhalation exposures, organ transplantation, certain drugs, and collagen vascular disorders. Individuals with this finding typically have shortness of breath on exertion, but may have normal chest X-rays and inconclusive findings on pulmonary function testing. Due to some similarities, symptoms of constrictive bronchiolitis may be attributed to asthma or chronic obstructive pulmonary disease (COPD).

Examiners may have a difficult time evaluating this population. In most cases, the affected soldiers are comfortable at rest and are able to perform the activities of daily living. They have normal or near normal pulmonary function tests, but at the same time they become short of breath on slight physical exertion, cannot meet physical training requirements, and are considered unfit for deployment. This unique circumstance challenges those who must determine a disability rating.

While individual exposure levels cannot be accurately determined, DoD considers constrictive bronchiolitis (initially diagnosed as “bronchiolitis obliterans”) to be plausibly associated with exposure to the 2003 Mishraq State sulfur fire event. This health effect has been scientifically associated with high exposures to SO2 .

Both sulfur dioxide and hydrogen sulfide are gases that can produce irritation and reddening of the nose and throat, eye irritation/pain, and coughing. At high levels, sulfur dioxide can burn the skin and can cause severe airway obstruction, hypoxemia, pulmonary edema, and even death. The firefighters involved with suppressing this fire experienced irritation, minor burns, and other effects such as blood-tinged nasal mucous. Some have been found to have long-term respiratory conditions such as “constrictive bronchiolitis.”

Note: If the claim is for a respiratory condition possibly related to the sulfur fire exposure consider requesting tests for “bronchiolitis” be conducted in addition to other respiratory testing, while noting that many standard test results may be normal.

This information is not meant to influence examiners rendering opinions concerning the etiology of any particular disability; but rather to ensure that such opinions are fully informed based on all known objective facts. Therefore, when rendering opinions requested by rating authorities for a disability potentially related to such exposure, please utilize this information objectively and together with the remaining evidence, including lay evidence, in the Veteran’s record.

From approximately April through September of 2003, Army National Guard (NG) personnel from Indiana, West Virginia, South Carolina, and Oregon operated at the Qarmat Ali Water Treatment Plant in Basrah, Iraq. They were assigned to guard contract workers who were restoring the plant. During that time, sodium dichromate, a source of hexavalent chromium was found on the ground and measured in the air. Hexavalent chromium, or Chromium VI (six), in sodium dichromate is a lung carcinogen through inhalation. Chromium VI is also an acidic compound that can cause immediate irritation of the eyes, nose, sinuses, lungs, and skin.

DoD provided a medical evaluation for certain soldiers there at the time, which took place in October 2003. Accordingly, 137 service members were evaluated. The results at the time showed some abnormalities in individuals, such as complaints of eye, nose, throat and/or lung irritation, or abnormal pulmonary function, kidney, or liver tests. However, the Army stated that it could not specifically trace these symptoms to chromium exposure.

The Veterans Health Administration (VHA) has begun to augment the Gulf War Registry to reflect service at Qarmat Ali. VHA is verifying the numbers of these Veterans who have either enrolled in care or received a Gulf War Registry examination. The involved Guard members who have had an initial examination will be recalled to have a complete exposure assessment as well as a more targeted physical examination and ancillary testing to detect indications of health outcomes that may be related to hexavalent Chromium. The Veteran, whose case you are reviewing, may or may not have completed this type of examination. Therefore, please be sure to review any such records if they exist in the VHA health record system for this Veteran.

This information is not meant to influence examiners rendering opinions concerning the etiology of any particular disability; but rather to ensure that such opinions are fully informed based on all known objective facts. Therefore, when rendering opinions requested by rating authorities for a disability potentially related to such exposure, please utilize this information objectively and together with the remaining evidence, including lay evidence, in the Veteran’s record.

_____________________
Adjudication Authority

FACT SHEET
Contaminated Drinking Water at Camp Lejeune, NC

NOTICE TO VA EXAMINERS
VBA Considers this Veteran Exposed to Contaminated Drinking Water

From the 1950s through the mid-1980s, persons residing or working at the U.S. Marine Corps Base at Camp Lejeune, North Carolina, were potentially exposed to drinking water contaminated with volatile organic compounds. Two of the eight water treatment facilities supplying water to the base were contaminated with either tricholoroethylene (TCE) or tetrachloroethylene (perchloroethylene, or PCE) from an off-base dry cleaning facility. The Department of Health and Human Services’ Agency for Toxic Substances and Disease Registry estimated that TCE and PCE drinking water levels exceeded current standards from 1957 to 1987 and represented a public health hazard. The heavily contaminated wells were shut down in February 1985, but it is estimated that over one million individuals, including civilians and children, may have been exposed.
There has been much public interest and media coverage of the potentially harmful health effects associated with the contaminated water supply at Camp Lejeune. The National Research Council of the National Academies of Science released a report in June 2009, which found that scientific evidence for any health problems from past water contamination is limited. The evidence for amounts, types, and locations of contamination were not well recorded at the time and cannot now be extrapolated. Therefore, conclusive proof of harmful health effects is unlikely to be resolved with any further studies.

This information is not meant to influence examiners rendering opinions concerning the etiology of any particular disability; but rather to ensure that such opinions are fully informed based on all known objective facts. Therefore, when rendering opinions requested by rating authorities for a disability potentially related to such exposure, please utilize this information objectively and together with the remaining evidence, including lay evidence, in the Veteran’s record.

The Department of Defense (DoD) has indicated that during the years between 1985 and 2001, personnel at Naval Air Facility (NAF) Atsugi, Japan were exposed to environmental contaminants. The source was an off-base waste incinerator business owned and operated by a private Japanese company. Know as the Jinkanpo or Shinkampo Incinerator Complex, the operation consisted of a combustion waste disposal complex equipped with four incinerators burning up to 90 tons of industrial and medical waste daily. The complex was located approximately 100 yards south of the NAF Atsugi perimeter and during the spring and summer months the prevailing winds would blow the incinerators’ emissions over the NAF.

Environmental assessment reports conducted during the years of incinerator operations stated that there was significant degradation of air quality at the sites sampled and identified the sources as incomplete burning of wastes in uncontrolled incinerators and evaporation of solvents poured onto outdoor waste piles prior to incineration. The identified chemicals of potential concern included: chloroform; 1,2-dichloroethane; methylene chloride; trichloroethylene; chromium; dioxins and furans; and other particulate matter.

Since the 1990s, the Navy has informed sailors and their family members about the possible long-term health effects of living at Atsugi. The Navy has also published various health information about Atsugi at the following website:

This information is not meant to influence examiners rendering opinions concerning the etiology of any particular disability; but rather to ensure that such opinions are fully informed based on all known objective facts. Therefore, when rendering opinions requested by rating authorities for a disability potentially related to such exposure, please utilize this information objectively and together with the remaining evidence, including lay evidence, in the Veteran’s record.

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SUBJ: Training Guide for the readjudication of Claims for Ischemic Heart Disease (IHD), Parkinson‟s Disease (PD), Hairy Cell Leukemia (HCL) and other Chronic B-cell Leukemias, and other Diseases Under Nehmer

BACKGROUND INFORMATION

On October 13th, 2009, Secretary Shinseki announced his intent to establish presumptive service connection for IHD, PD, and HCL for Veterans who served in the Republic of Vietnam. This decision was based on the Institute of Medicine‟s seventh biennial update, “Veterans and Agent Orange: Committee to Review the Health Effects in Vietnam Veterans and Exposure to Herbicides.” Under the court order of the U.S. District Court for the Northern District of California (the “Court”) in Nehmer v. U.S. Department of Veterans Affairs, 712 F. Supp. 1404, 1409 (N.D. Cal. 1989), VA must readjudicate previously denied claims for IHD, PD, or HCL filed by Nehmer class members (Vietnam Veterans and their survivors) and provide retroactive benefits pursuant to 38 C.F.R § 3.816. This requirement involves claims filed or denied from September 25, 1985, to the effective date of VA‟s final regulation establishing a presumption of service connection for the disease claimed. Such claims may not be finally adjudicated until VA‟s regulation change at 38 C.F.R. § 3.309(e) is final, which will add these three diseases to the list of diseases associated with herbicide exposure.

ACCOUNTABILITY

Resource Centers, who are responsible for the readjudication of Nehmer claims, must strictly comply with the instructions set forth in this letter and the attached Training Guide. It is critical that Nehmer claims be handled expeditiously and correctly. The processing of Nehmer claims requires VA to operate under court- imposed deadlines. Failure to comply with instructions could result in court- ordered sanctions against VA and/or VA officials.

Regulatory Guidance

A proposed regulation was recently published in the Federal Register Vol. 75,
14391 (March 25, 2010) that would amend 38 C.F.R. § 3.309(e) by adding IHD,
PD, and HCL to the list of diseases presumptively associated with exposure to
herbicides in Vietnam. Publication of the final rule is expected in the near future.

Whom to Contact for Help

If you have questions or need additional information, e-mail your inquiry to the
Q&A mailbox at VAVBAWAS/CO/NEHMER.

The purpose of this training guide is to provide users with the information
necessary to review, develop, rate, and authorize Nehmer claims for the three
new presumptive conditions – hairy cell leukemia and other chronic B-cell
leukemias (HCL), Parkinson‟s disease (PD), ischemic heart disease (IHD), and
any other presumptive conditions involving in-country Vietnam service.

This guide will enable you to:

1. Review the claims folder and readjudicate all claims that previously denied a class member‟s claim for service connection for a new presumptive disease
2. Identify the eligibility requirements that qualify a Veteran or survivor for retroactive awards of benefits under Nehmer
3. Identify what constitutes a prior claim of benefits for conditions presumptively related to herbicide exposure under Nehmer
4. Identify the three new and current presumptive conditions associated with herbicide exposure
5. Identify and correctly apply effective date rules for a Nehmer claim
6. Determine what type of development, if any, is needed for rating or authorization
7. Determine requirements for authorization of awards pursuant to Nehmer
8. Identify the requirements of the decision notice letter.

BACKGROUND

The Nehmer court case originated in 1986 as a class-action lawsuit against the Department of Veterans Affairs (VA) by Vietnam Veterans and their survivors, who alleged that VA had improperly denied their claims for service-connected compensation for disabilities allegedly caused by exposure to the herbicide Agent Orange in service. In 1989, the United States District Court for the Northern District of California (Court) ruled that VA's regulation was invalid because the causation standard that it used was inconsistent with the intent of Congress. The Court invalidated VA's regulation and voided all benefit denials made under that regulation.

In May 1991, the Nehmer parties entered into a "Final Stipulation and Order" (Final Stipulation) outlining the actions to be taken in response to the Court's decision. Among other things, the Final Stipulation provided:
(1) that VA would issue new regulations in accordance with the Agent Orange Act of 1991;
(2) that, after issuing such regulations, VA would readjudicate the claims where a prior denial was voided by the Court's 1989 order and would initially adjudicate all similar claims filed subsequent to the Court's order; and
(3) that, if benefits were awarded upon such readjudication or adjudication, the effective date of the award would be the later of the date the claim was filed or the date the disability arose.
Ordinarily, if a claim is granted on the basis of a new regulation, the law states that the effective date of the award may not be any earlier than the date on which the regulation went into effect.

In a February 1999 decision, the Court clarified the scope of its 1989 decision. It voided all VA decisions that were issued while the invalid regulation was in effect and which denied service connection for a Vietnam Veteran's disease that was later found to be associated with herbicide exposure under new regulations. In December 2000, the Court provided further clarification when it concluded that VA must pay the full retroactive benefit to the estates of deceased class members.

On October 13, 2009, the VA announced Secretary Shinseki‟s decision to establish presumptive service connection for three additional illnesses associated with exposure to herbicides used in Vietnam based on an independent study conducted by the Institute of Medicine. The illnesses affected by the recent decision are B-cell leukemias (such as hairy cell leukemia), Parkinson‟s disease, and ischemic heart disease. A proposed rule adding these three conditions to VA‟s list of presumptive diseases was published in the Federal Register on March 25, 2010, 75 Fed. Reg. 14,391.

Approximately 94,000 Vietnam Veterans and survivors were previously denied service-connection (between September 1985 and end of month April 2010). An additional number of new claims have been received since the Secretary announced his intention to add three new conditions to the presumptive list. All of these claims must be adjudicated/readjudicated in order to comply with the Final Nehmer Stipulation.

REFERENCES

The following references are useful in the review and adjudication of Nehmer
claims:

Traditional Claims: All other claimants and all periods of service for benefits.

Nehmer: Nehmer class members are Vietnam Veterans who served in-country and have a covered herbicide disease, or the surviving spouse, child, or parent of a Vietnam Veteran who died from a covered herbicide disease.

Effective Dates

Traditional Claims: The date the claim resulting in award was filed or date entitlement arose, whichever is later, but in no event prior to the effective date or the regulatory resumption of service connection.

Nehmer: The date the original claim was filed or arose, whichever is later, even if it was before the effective date of applicable regulatory presumption, and without regard to finality of prior denial(s)
(Contrary to 38 U.S.C. § 5110(g), 38
C.F.R. § 3.400).

Effective dates can go back as far as the date of claim that was pending on September 25, 1985 (The date the rules implementing “Veterans‟ Dioxin and Radiation Exposure Compensation Standards Act,” Pub. L. 98-542 (Oct. 24, 1984) were effective in the Code of Federal Regulations).

Need to File Claim

Traditional Claim: The claimant must file original claim. If claimant alleges earlier effective date, claimant must demonstrate that he or she made an earlier claim that did not become final.

Nehmer: The claimant need not file a new claim or a claim for earlier effective date when new presumptive condition is added. VA must search its records to find eligible claimants and award benefits, without action on the claimant‟s part.

Medical records noting the existence of a condition later made presumptively service-connected can in some instances, result in an award without a formal claim ever being filed

Eligible Payees

Traditional Claim: Veteran or surviving spouse, children or dependent parents of the Veteran can get accrued or owed benefits.

Benefits never go to the estate because the right to benefits ends with death of the entitled individual.

The one who bore the last expenses can claim reimbursement from benefits owed.

Nehmer: Payee may not be identified in Veteran‟s claims folder because the claim survives the Veteran and his spouse; requires further documentation for proof of entitlement (e.g., marriage certificate, birth certificate). VA must request those documents needed to establish eligibility.

Traditional Claim: Payment is made when the benefit is granted in agency‟s course of business.

Priorities are decided nationally and locally based on Department‟s policies.

Nehmer: The timing of payments is governed by court order. Payment is required to be received within twenty-one days of receipt of information confirming entitlement (the twenty-one day period begins once the whereabouts of a class member is known).

Nehmer claims must be handled as a first priority, under court-ordered deadlines.

Nehmer: The VA notice letter must include an explanation of how the amount was calculated.

Proof of Payment

Traditional Claim: N/A

Nehmer: A copy of Treasury Inquiry screens indicating proof of payment may be provided to class counsel upon request.

Time Limit

Tradtional Claim: If the applicant fails to provide requested information within one year, a decision is made on the available evidence. This decision is considered final.

Nehmer: There is no time limit imposed for submission of evidence by a claimant.

Retired Pay / SBP Offset Issues

Traditional Claim: Retired pay/SBP offset is determined by computer at DFAS in the normal course of business.

Nehmer: Because benefits may be owed from over 20 years ago, offset amount must be retrieved from DFAS database.

Court Supervision

Traditional Claim: The VA is subject to normal oversight by OIG and Congress.

Nehmer: Deadlines are court imposed, and class counsel oversees VA compliance. When the timeline is not met, VA must provide a declaration signed under oath by the persons with knowledge setting forth the steps taken to meet the deadline, an explanation of the delay, and the date by which VA will provide payment/notice.

EAJA Fees

Traditional Claim: EAJA fees may be awarded in certain appeals of denied claims.

Nehmer: VA compensates class counsel for all its work on Nehmer claims.

Processing

Traditional Claim: Processing occurs within normal VA channels.

Nehmer: Virtually all Nehmer claims require special handling.

Nehmer vs. 38 C.F.R. § 3.114(a)

By definition, if a case falls under Nehmer, it means that the first claim of service connection for the condition at issue was received BEFORE the condition was added to the list of Agent Orange-related disabilities and the effective date for the grant of service connection will also be BEFORE the condition was added to the list of Agent Orange-related disabilities. As a result, if a claim was received before the condition was added to 38 C.F.R. § 3.309(e), the case is a potential Nehmer case. On the other hand if the claim was received after the disease was added to the presumptive list, it is not a Nehmer case. In those cases 38 C.F.R. § 3.114(a) applies and the earliest effective date that can be granted under 38 C.F.R. § 3.114(a) is the date on which the liberalizing legislation was effective (i.e. the date on which the condition was added to 38 C.F.R. § 3.309(e) or one- year prior to date of claim, whichever is later).

Remember that in all cases, the condition must have been present on the date we grant service connection. Occasionally, we receive a claim BEFORE the condition is actually present, and neither Nehmer nor 38 C.F.R. § 3.114(a) allows for a grant of service connection prior to a confirmed diagnosis.

The Nehmer claims workflow process differs from the traditional claims processing that the reviewer normally sees. Appendix 5 shows an overview of the “Workflow for Processing Nehmer Claims.”

According to Harrison‟s Principles of Internal Medicine (Harrison‟s Online, Chapter 237, Ischemic Heart Disease, 2008), ischemic heart disease is a condition in which there is an inadequate supply of blood and oxygen to a portion of the myocardium; it typically occurs when there is an imbalance between myocardial oxygen supply and demand. Therefore, for purposes of this regulation, the term “ischemic heart disease” includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable, and Prinzmetal‟s angina. Since the term refers only to heart disease, it does not include hypertension or peripheral anifestations of arteriosclerosis such as peripheral vascular disease or stroke.

The cardiovascular section of the rating schedule was revised effective January 12, 1998 (See the Rating section for further information).

Definition of Chronic B-Cell Leukemia

B-cell leukemia describes several different types of lymphoid leukemias and includes the following types:

Parkinson's disease (PD) belongs to a group of conditions called motor system disorders, which are the result of the loss of dopamine-producing brain cells. The four primary symptoms of PD are tremor, or trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination. As these symptoms become more pronounced, patients may have difficulty walking, talking, or completing other simple tasks. PD usually affects people over the age of 50. Early symptoms of PD are subtle and occur gradually. In some people the disease progresses more quickly than in others. As the disease progresses, the shaking, or tremor, which affects the majority of PD patients may begin to interfere with daily activities. Other symptoms may include depression and other emotional changes; difficulty in swallowing, chewing, and speaking; urinary problems or constipation; skin problems; and sleep disruptions. There are currently no blood or laboratory tests that have been proven to help in diagnosing sporadic PD. Therefore the diagnosis is based on medical history and a neurological examination. The disease can be difficult to diagnose accurately. Doctors may sometimes request brain scans or laboratory tests in order to rule out other diseases.

NOTE: See Appendix 1 for the complete list of presumptive conditions associated with herbicide exposure.

READJUDICATION REQUIREMENTS UNDER THE NEHMER COURT ORDER

The Nehmer Court has held that the stipulation requires VA to readjudicate all cases in which VA previously denied a class member‟s claim of service connection for a new presumptive disease. A prior denial based on lack of diagnosis rather than lack of nexus falls within the scope of the stipulation‟s requirement for readjudication. This differs from claims in which there was no prior claim or class member status (i.e., no in-country Vietnam service, no “Veteran” status, etc).

CLASS MEMBERS UNDER THE NEHMER COURT ORDER

38 C.F.R. § 3.816 (b)(1) defines the class members as: (i) a Vietnam Veteran who has a covered herbicide disease; or (ii) a surviving spouse, child, or parent of a deceased Vietnam Veteran who died from a covered herbicide disease.

38 C.F.R. § 3.816 (f)(1) states that if a Nehmer class member entitled to retroactive benefits . . . dies prior to receiving payment of any such benefits, VA shall pay such unpaid retroactive benefits to the first individual or entity listed below that is in existence at the time of payment:

(i) The class member's spouse, regardless of current marital status
 A spouse is the person who was legally married to the class member at the time of the class member‟s death
(ii) The class member's child(ren), regardless of age or marital status
 If more than one child exists, payment of the retroactive benefits owed shall be divided into equal shares, and accompanied by an explanation of the division; this includes all children, regardless of age or marital status
(iii) The class member's parent(s), regardless of dependency
 If both parents are alive, half the retroactive benefits owed shall be paid to each parent, and accompanied by an explanation of the division
(iii) The class member's estate

ELIGIBILITY REQUIREMENTS FOR RETROACTIVE PAYMENT PURPOSES

If a Nehmer class member is entitled to disability compensation for a covered herbicide disease, eligibility requirements must be met. The eligibility requirements are:

 The Veteran served in the Republic of Vietnam; and
 They have applied, were denied, or a claim was inferred (by class member or VA) for benefits for one of the three new presumptive conditions between September 25, 1985, or a date prior to September 25, 1985, if the claim was pending or on appeal on September 25, 1985, and the date the regulations for these conditions become effective; and
 They are diagnosed with one of the presumptive diseases, or a disease that reasonably may be construed as a covered herbicide disease.

EFFECTIVE DATES FOR RATING PURPOSES

The effective date for retroactive claims must be one of the following dates:

 The later of the following:
- The date VA received the claim, or a date prior to September 25, 1985, if the claim was pending or on appeal on September 25, 1985,
or
- The date the disability arose
 The day following the date of the class member's separation from active service, if filed within one year from the date of separation

The effective date for Dependency and Indemnity Compensation (DIC) claims must be one of the following dates:

 The date VA received the claim, or
 The first day of the month of the Veteran‟s death, if filed within one year from the date of the Veteran‟s death

NOTE: If the class member‟s claim for DIC for the death was either pending before VA on May 3, 1989, or was received by VA between that date and the effective date of the statute or regulation establishing a presumption of service connection for the covered herbicide disease that caused death, the effective date of the award will be the later of the date such claim was received by VA or the death occurred (38 C.F.R. § 3.816(d)(2)).

Veterans can establish proof of service in the Republic of Vietnam (RVN) if they were:

 On land in the RVN, or
 In the inland waterways of RVN, or
 In vessels docked at the ports of RVN, or*
 In waters offshore of RVN, if the conditions of service involved duty, or visitation on the ground in RVN, or
 Other locations, if the conditions of service involved duty or visitation on the ground in RVN

* For a list of vessels confirmed to have docked on the RVN shore or traveled on inland waterways, see Appendix 2.

There is no requirement for a specified length of service, duty, or visitation in RVN. See 38 C.F.R. § 3.307(a)(6)(iii) for more information.

The following sources may be used to verify service in RVN If they served in RVN during the period beginning January 9, 1962, and ending on May 7, 1975:

For a list of APOs that are verified by the Military Postal Service Agency as used for delivery to RVN, see Appendix 4.

CLAIMS FOR BENEFITS

Veterans must have applied for or have been denied benefits for one of the three new presumptive conditions between September 25, 1985, (or a date prior to September 25, 1985, if the claim was pending or on appeal on September 25, 1985) and the date the regulation for these conditions becomes effective.

A claim meeting the eligibility requirements of Nehmer can be any of the following:

 A claim for Service Connection (SC)
 An informal claim
 A pension claim
 An inferred claim for SC
 A claim inferred by Veteran or VA during review
 Notice of Death
 A claim for burial benefits
 A claim for DIC, death pension or accrued benefits
 Social Security Administration - VA Form 21-4182, Application for Dependency and Indemnity Compensation or Death Pension
 VA Form 21-601, Application for Accrued Amounts Due A Deceased Beneficiary

Additional factors:

 A claim need not reference herbicide exposure (See Example 1)
- In its February 11, 1999, Nehmer order, the Court held that a Nehmer class member‟s compensation claim need only have requested service connection for the presumptive condition in order to qualify as a Nehmer claim. It is not necessary that the class member assert the condition was caused by herbicide exposure
 An initial claim may lack specific details, which were clarified by later submissions (See Example 2)
 A prior claim must have involved one or more of the three new presumptive conditions, or one that reasonably may be construed as the same covered herbicide disease for which compensation has been awarded (See Examples 3 and 4)
 Live pension claims must be treated as SC claims (See Example 5)
- Under 38 C.F.R. § 3.15 (a), “a claim by a Veteran for pension may be considered to be a claim for compensation.” VA is not required by law to treat a Veteran‟s claim for pension as a claim for compensation, see Stewart v. Brown, 10 Vet. App. 15, 18 (1997), but may do so in appropriate circumstances. Nehmer is an appropriate circumstance
 Death pension claims must be treated as DIC claims (See Example 6)
 A claim of SC burial benefits must be treated as an informal DIC claim in certain circumstances. For more information, see the Rating section, subsection Claims for Service-Connected Death and for scenarios see Examples 7, 8 and 9 below.
- An open claim:

-- An instance where VA failed to provide a decision notice letter to the claimant

-- An instance where VA failed to address a claim, such as an inferred or an informal claim (or failed to address an appeal)

-- An instance where VA failed to provide an application for benefits to a claimant

Examples of Claims

Example 1: A Veteran who served in the Republic of Vietnam filed a claim in 1994, alleging that his IHD, PD, or HCL began while on active duty following his service in Vietnam. VA denied the claim in 1995. The Veteran reopens the claim in 2010, and service connection is granted based on VA‟s amended herbicide regulations. On these facts, the effective date must relate back to the 1994 claim, even though the Veteran alleged a different basis for service connection.

Example 2: In January 1987, a Veteran claimed compensation for lymphoma. In developing that claim, VA obtained medical records indicating that the Veteran was diagnosed with HCL in February 1987. Based on these facts, it would be reasonable to treat the January 1987 claim as a claim for service connection for HCL. Under Nehmer, benefits may be paid retroactive to the date of that claim or the date the disability arose, whichever is later, as determined by the facts of the case.

Example 3: In April 1995, a Veteran claimed compensation for anemia/leukemia. Medical records obtained by VA indicate the Veteran did not have leukemia. The claim was denied in 1995. In 2001, the Veteran claimed compensation for HCL, submitting evidence that HCL was diagnosed in January 1996. The Veteran did not file an appeal based on the 1995 decision and there was no activity from the Veteran until 2001. Based on these facts, the 1995 claim and evidence submitted did not show a diagnosis of HCL or the presence of any type leukemia. The 2001 submission of evidence was accepted as a reopened claim with a confirmed diagnosis. Under these facts, the effective date would be 2001, as that is when VA received evidence documenting the diagnosed disability.

Below are slightly different modifications of the above scenario that would change the outcome.

For example, if the records diagnosing HCL existed during the pending 1995 claim, and the Veteran, in any manner, communicated to VA the existence of those records and VA failed to obtain them (possibly because VA assumed they would be of no help to the claim since there was no presumption at the time), then the effective date would be April 1995 because VA failed in their duty to obtain records identified by the claimant.

Another slight variation would exist if the Veteran actually submitted the records diagnosing HCL in 1996 to VA following such diagnosis. The 1995 claim was properly disposed of in 1995, and VA received the 1996 records in 1997, but received no accompanying information from the Veteran regarding any intent to file a claim, then the proper effective date under the Nehmer review would be when VA received the records in 1997 rather than 2001. Because the Nehmer review requires VA to readjudicate these claims “as if” the presumption existed in 1985, then submission of records confirming a diagnosis of the presumptive condition must serve as a valid claim, despite VA‟s failure to act on such records and notwithstanding that no presumption existed when VA actually received the records.

Example 4: A Veteran filed a formal claim for service connection for IHD, PD, or HCL in November 1979 and VA denied the claim in January 1980. In May 1986, the Veteran submitted a letter stating, “please consider service connection for IHD, PD, or HCL,” along with documentation showing a diagnosis for one of these conditions. On these facts, the May 1986 letter is an acceptable formal claim to reopen, and benefits must be paid retroactive to May 1986 under Nehmer.

Example 5: In 1994, a Veteran filed a claim for nonservice-connected (NSC) pension. After VA denied the claim, the Veteran filed a statement in 1995 stating, “I disagree with your decision denying pension.” I also should be paid compensation for IHD, PD, or HCL.” VA did not forward the claimant an application form and did not adjudicate any claim for service connection for IHD, PD, or HCL. On these facts, both the 1994 pension claim and the 1995 statement must be accepted as a claim for IHD, PD, or HCL.

Example 6: A Veteran died of IHD, PD, or HCL. In 1988, the surviving spouse filed a VA Form 21-534, Application for DIC or Death Pension or Accrued Benefits by a Surviving Spouse or Child, and marked “no” in response to the question “are you claiming that the cause of death was due to service?” Accordingly, VA adjudicated a claim for pension only. In 2009, the surviving spouse applies for DIC, which is granted. Under these circumstances, the award must be made retroactive to the 1988 application, because it must be treated as a DIC claim.

DIC claimants generally are not required to identify specific diseases in their applications. The absence of specific reference to IHD, PD, or HCL in a prior DIC application will not preclude assignment of a retroactive effective date under Nehmer, provided the evidence establishes that IHD, PD, or HCL caused or contributed to the Veteran‟s death.

Example 7: In 1995, a surviving spouse filed an application for burial benefits (VA Form 21-530, Application for Burial Benefits) and marked “yes” in response to the question “are you claiming that the cause of death was due to service?” VA forwarded the claimant an application for DIC (VA Form 21-534). The claimant returned the completed DIC application within one year. Based on these facts, the date of the 1995 application for burial benefits may be accepted as the date of the DIC claim for purposes of Nehmer.

Example 8: In 1995, a surviving spouse filed an application for burial benefits (VA Form 21-530) and marked “yes” in response to the question “are you claiming that the cause of death was due to service?” VA forwarded the claimant an application for DIC (VA Form 21-534), but the claimant failed to return the completed DIC application. Based on these facts, the 1995 application for burial benefits should not be considered a claim for DIC.

Example 9: In 1995, a surviving spouse filed an application for burial benefits (VA Form 21-530) and marked “yes” in response to the question “are you claiming that the cause of death was due to service?” VA did not forward an application for DIC. Based on these facts, DIC must be paid retroactive to the 1995 application for burial benefits, if otherwise in order. The one-year period for filing a completed DIC application did not begin due to VA‟s failure to provide the application form.

DIAGNOSIS OF PRESUMPTIVE DISABILITIES

The evidence must show a diagnosis of one of the presumptive conditions and the date of the diagnosis. A prior denial of a claim for a presumptive disability based on lack of a diagnosis falls within the scope for readjudication, however the effective date for any disability cannot precede the diagnosis.

Example 1:
The Veteran submitted a claim for service connection for ischemic heart disease due to herbicide exposure on May 2, 1995. He served in Vietnam; therefore, herbicide exposure is conceded. Testing confirmed hypertensive vascular disease on April 5, 1995, but not ischemic heart disease, so a decision letter was sent to the Veteran denying service connection for ischemic heart disease. On March 3, 2010, VA administratively reviewed the claims file due to ongoing Nehmer litigation. The evidence on file showed VAMC treatment records with a diagnosis of ischemic heart disease on April 19, 1997. The medical records did not have a date stamp or any other annotation showing when VA received them. The medical records were accepted as a reopened claim and resulted in a denial of service connection by rating dated May 15, 1998. Based on these facts, the Veteran was granted service connection from April 19, 1997. Although, the Veteran filed a claim on May 2, 1995, a diagnosis was not shown until April 19, 1997. In addition, 38 C.F.R. § 3.816(c)(1) states that the effective date of the award will be the later of the date VA received the claim on which the prior denial was based or the date the disability arose.

Example 2:
A review of the claims folder shows that an original claim was filed on April 5, 1995, for service connection for heart disease (not IHD) and high cholesterol. The medical evidence for the period March 1993 and April 1995 showed a diagnosis of high cholesterol and a history of heart disease. Development action(s) was not undertaken and the SC claim was denied in June 1996. Based on these facts, VA failed to confirm a diagnosis and the Nehmer stipulation requires that we readjudicate claims for new presumptive conditions that were previously denied.

Example 3:
A review of the claims folder shows that an original claim was filed on June 5, 1996, for service connection for IHD and high cholesterol. The veteran served in-country Vietnam from 1969 to 1971. The medical evidence of record for the period March 1993 and April 1996 showed a diagnosis of high cholesterol and a history of heart disease. A VA examination dated September 7, 1996, showed a diagnosis of high cholesterol and IHD. Based on these facts, the claim was denied SC June 1997. The Nehmer stipulation requires that we readjudicate claims for new presumptive conditions that were previously denied.

NEHMER DATABASE

The Nehmer Reajudication Database (also known as the Nehmer database) facilitates the claims folder review by providing the user with questions that are necessary to process a Nehmer claim. The information gathered not only enables the claims folder review process, but also provides a data collection mechanism that is used for reporting data to VBA, the Secretary of Veterans Affairs, the Office of General Counsel (OGC), the Department of Justice, and, if necessary, the Court.

It is imperative that the database is utilized and all information is saved in the database during the claims folder review. In previous Nehmer readjudications, inaccurate reporting and failure to adequately track and document work resulted in the Court issuing “Show Cause” orders regarding why VA and VBA supervisors should not be held in contempt.

Upon completion of the readjudication of the file in the database, the reviewer will be responsible for incorporating a printout of the completed worksheet into the claims folder.

END PRODUCT CONTROL

The date of claim and end product (EP) 687 will be established in the Nehmer database. If a Nehmer claim is NOT in the database, notify Southern Area Office immediately. Do NOT attempt to establish an EP until notified of the database modification and the correct date of claim. ONLY then proceed to establish the EP and the correct date for date of claim.

The e-mail address for Southern Area Office can be found in Appendix 6.

CLAIMS FOLDER REVIEW

A systematic review of the entire claims folder is required to determine if the individual is a Nehmer class member and if the eligibility requirements for retroactive payments under Nehmer are met.

If the individual is a Nehmer class member, the reviewer must ensure the following actions are taken:

If the individual is not a Nehmer class member, forward to the RVSR for a Memorandum for the Record. For more information regarding Memorandums for the Record, see the Rating section.

Check the claims folder for medical evidence required for a rating decision. If a VA Examination (VAE) is necessary, proceed with scheduling the examination immediately.

For cases involving death, be sure to check for proof of death and proof of dependency. If burial was also involved, check to see if an itemized funeral bill and a paid-in-full receipt showing who paid the funeral bill are of record.

During the screening process, if medical evidence is sufficient to grant partial benefits, send to the RVSR. Proceed with development if necessary information is not of record.

NOTE: If no additional development is required, send the MAP-D Notification/Development Paragraphs for Nehmer to the class member (See Appendix 12).

IMPORTANT: Detailed, but concise notes should be added in Modern Awards Processing – Development (MAP-D) throughout the claims review. After completion of review, the data must be entered into the Nehmer database to track all actions associated with the claim.

DEVELOPMENT

Development may be required following the claims folder review. This may include development for medical evidence, service, dependency, payee, military pay, and/or burial information. Use MAP-D to generate the development letters. See Appendix 12 for the appropriate paragraphs to use in development letters. Be sure to use considerate language when developing these claims, especially in death cases. Most cases identified as Nehmer claims have been denied many years ago.

Medical Evidence

Due to the inherent nature of Nehmer cases, it may be difficult to obtain a complete medical history of the Veteran. The development of evidence in connection with claims for service connection will be accomplished when deemed necessary, but it should not be undertaken when evidence present is sufficient for this determination (38 C.F.R. § 3.304(c)). When the evidence of record is sufficient to grant benefits, but a current assessment of the medical condition(s) is necessary, VAE may be appropriate. Consult with the RVSR to determine if medical records are sufficient for rating.

Example

IHD with multiple heart attacks since denial ten years ago, and evidence in file would have warranted a 60 percent evaluation.

Medical evidence, lay evidence, or both may establish the factual basis for a decision. Medical evidence should set forth the physical findings and symptomatology elicited by examination within the applicable period. Lay evidence should describe the material and relevant facts as to the Veteran‟s disability observed within such period, not merely conclusions based upon opinion. See 38 C.F.R. § 3.307(b).

In order to pay DIC and burial benefits, a death certificate or other proof of death is required showing the date of death and the cause(s) of death. See 38 C.F.R. § 3.211 for additional sources of proof of death.

Service

If unavailable in the Veteran‟s records, verification of service may be obtained by performing a Defense Personnel Records Information Retrieval System (DPRIS) request.

Verification of the Veteran‟s pay grade is required if the Veteran died prior to December 31, 1992. Check the Veteran‟s DD Form 214 for pay grade. If the evidence of record cannot determine the pay grade, request service records from the service department through DPRIS.

For more information on using DPRIS for service verification, please see the respective User Guides.

Dependency

Use the following table to determine what information is required to establish dependency. Please note that this is not an all-inclusive list.

Evidence Requirements for Dependency Dependent Evidence Required

Spouse
- Date of marriage to Veteran
- Number of prior marriage(s)
- Name(s) of prior spouse(s)
- Date(s) and place(s) of termination of prior marriage(s) for both the Veteran and spouse
- Social Security Number (SSN)
- Continuous cohabitation
- Remarriage after death of the Veteran

Biological Child
- Date of birth
- SSN

Stepchild
- Date of birth
- Birth Certificate
- SSN
- Date child was in the household of the Veteran

Children between ages 18 and 23 who are attending school at an approved institution may receive DIC benefits. Before the claim can be processed, it may be necessary to gather information regarding school attendance dates and other information. Additionally, information on Dependents‟ Educational Assistance (DEA) should be checked to prevent concurrent receipt of benefits.

Development of dependency information may be made over the telephone, through facsimile, or by letter.

For more information on developing for dependency see M21-1MR, Part III, Subpart iii, Chapter 5 (M21-1MR III.iii.5).

The right to benefits survives entitled member (contrary to 38 U.S.C. § 5121).

Continuous Cohabitation

The requirement that there must be continuous cohabitation from the date of marriage to the date of death of the Veteran will be considered as having been met when the evidence shows that any separation was due to the misconduct of, or procured by, the Veteran without the fault of the surviving spouse. Temporary separations, including those caused for the time being through fault of either party, will not break the continuity of the cohabitation.

Common Law Marriage

To view a list of states that recognize common law marriage, please refer to “Recognition of Common Law Marriages by State” in M21-1MR III.iii.5.C.14.a.

Payee

As these are potentially old cases, it may be necessary to develop for payees for the retroactive benefits. Send letters to all dependents of record requesting the names, addresses, and telephone numbers of all known survivors.

Additionally, proof of dependency is required before retroactive benefits may be paid. Develop for birth certificates, marriage certificates, and other proof of dependency if necessary.

If payees cannot be identified, VA must make such reasonable inquiry as the information on file permits. For example, if the claims folder identifies an authorized representative or a relative, it would be reasonable to contact such person to request information concerning the existence of a surviving spouse, child(ren), parent(s), or the executor/administrator of the class member’s estate.

If any such payee cannot be identified or located:

- Complete VA Form 21-0820, Report of General Information, for the folder stating the reasons why the payment of retroactive Nehmer benefits was not payable to a beneficiary
- Notify Nehmer Project Manager by e-mail that no payee could be identified, including the claimant‟s name and file number in the message

NOTE: Refer to the Eligibility Requirements section for a list of eligible payees and order of entitlement.

Military Pay

38 U.S.C. § 5305 prohibits, in some cases, Veterans from receiving full military retirement pay and VA compensation benefits at the same time. In order to properly withhold benefits and prevent overpayments, DFAS has provided a database listing retired pay, severance and separation pay, and Survivor Benefit Plan (SBP) amounts and effective dates.

NOTE: Before developing, verify the Veteran waived his or her military pay in lieu of compensation. This can be found on VA Form 21-526, Veteran's Application for Compensation and/or Pension, or VA Form 21-651, Election of Comp in Lieu of Retired Pay or Waiver of Retired Pay to Secure Comp from VA.

NOTE: A waiver may not be included on some versions of VA Form 21-526. A copy of Form 21-651 must be of record or obtained from the class member.

Burial

The following information may need to be requested from the survivor, funeral home or cemetery:

- Proof of death
- Receipt showing the total cost of the funeral and who made payment
- Itemized list of funeral expenses
- Place of burial

NOTE: Contacting the funeral home or cemetery for this information over the telephone may expedite the process.

IMPORTANT REMINDER: Detailed notes should be entered into MAP-D.

After completion of Development, the Nehmer Database should be updated to track all actions associated with the individual‟s claim.

RATING

Memorandum for the Record

A memorandum for the record is used only when the individual is not a Nehmer class member (i.e., no prior claim, no “Veteran” status, etc). If it is determined the individual is not a Nehmer class member, then a Memorandum for the Record is required. A notice letter is not sent to the individual.

A detailed explanation regarding why the individual is not a class member is required. The explanation must be sufficient in detail for the reviewer to undertake a clear analysis as to why the case does not qualify for Nehmer readjudication. See Appendix 7 for sample Memorandums for the Record.

NOTE: The example Memorandums for the Record that appear in Appendix 7 are modifications of an actual form used in previous Nehmer readjudications. For the purposes of this Nehmer review, use the memorandums as shown with no form number. In no instance, when using these forms, should there be any reference made to rating. Some examples where VA may not, under any circumstance, dispose of a case using a memorandum for the record include:

1. A Veteran filed a claim expressly for one of the new presumptive diseases

2. A Veteran filed a claim for a disease that may be reasonably construed as a covered herbicide disease

3. A Veteran filed a claim that did not directly address a covered herbicide disease but that did raise an issue potentially intertwined with a covered disease, such as hypertensive heart disease, but VA failed to fully develop that claim in order to rule out or confirm the diagnosis of hypertensive heart disease, or any other potential covered disease

4. Any case where VA reviews a claims folder and discovers evidence in the file of a covered herbicide-related disease

Examples of Memorandums for the Record:

Example 1:

In 1993, the individual filed a claim for service connection for HCL. The medical evidence did not show a diagnosis of HCL. The individual served from 1969 to 1974 (one consecutive period of service) and received a bad conduct discharge. The claim was denied in 1994 based on no diagnosis. Based on these facts, the individual is not a Nehmer class member, as he did not have “Veteran” status. A memorandum for the record is in order.

Example 2:

In 1987, the Veteran filed a claim for service connection for lupus. The medical evidence of record shows a diagnosis of lupus. The individual served from 1969 to 1978. The claim was denied in 1989. The rating disposed of the SC claim for lupus, and the incorrect rating disability code (8004-currently used for PD) was used. The notification letter and rating decision only addressed lupus and did not reference PD. Based on these facts, the individual is not a Nehmer class member, as he did not have a prior claim for service connection for a new presumptive disease, or a diagnosis. A memorandum for the record is in order.

Example 3:

In 1995, the Veteran filed a claim for heart disease. The medical evidence submitted with the claim confirmed the diagnosis. The evidence shows the Veteran served in the Air Force from 1965 to 1975 and has verified in-country Vietnam service from 1970-1972. A VA examination was not ordered and no additional development for any medical records was undertaken. The claim for service connection was denied in 1997. The review raised doubt as to whether or not the heart disease could be considered a claim for the new presumptive disease. Based on these facts, it is reasonable to construe the 1995 claim as claim for the new presumptive disease and a readjudication of the claim is required.

Example 4:

The Veteran filed a claim for hypertension and the medical evidence of record indicated treatment for a heart condition with medication. The claim was denied for hypertension only. In this situation, there is an indication that the Veteran had a heart condition. Based on these facts, the Veteran would be considered a Nehmer class member and readjudication of the claim is required.

A slightly different variation to the above scenario would change the outcome. The Veteran claimed hypertension, and the evidence showed a diagnosis of hypertension. Service connection for hypertension was denied. Based on these facts, we do not have a claim nor do we have a diagnosis of a new presumptive disease. In this situation, a memorandum for the record is in order.

WARNING
If there is any doubt about whether or not an individual is
a Nehmer class member, readjudicate the claim. Do not
prepare a Memorandum for the Record.

NOTE: It is anticipated that Memorandums for the Record will not be frequently used and the least likely used will be “no prior claim,” because of the liberal interpretation of a claim. Additionally, because the Nehmer stipulation requires VA to readjudicate all claims that were previously denied, it is also unlikely that “no diagnosis” will be frequently used.

Confirmed and Continued Rating

If classified as a Nehmer class member and eligibility requirements for Nehmer claims are met, but there is no change to the decision in the previous claim, you should issue a confirmed and continued rating.

If a prior claim for compensation or DIC for disability or death due to IHD, PD, or HCL was denied for some reason other than a lack of service connection, and there is no basis for awarding an earlier effective date under Nehmer, contact C&P Service. Please refer to Appendix 6 for contact information.

Examples
- If the prior claim was denied because there was no evidence that the
Veteran had IHD, PD, or HCL, and VA confirms no diagnosis during
readjudication, retroactive benefits would not be in order
- If the prior claim was abandoned or withdrawn, there would not be a basis
for retroactive payments under Nehmer

Coded Ratings

If classified as a Nehmer class member and eligibility requirements for Nehmer claims are met, and the claim is ready-to-rate, the following sections pertain to rating claims for service connection, service-connected death benefits, and claims involving service connection combined with service-connected death benefits.

Total Disability Based on Individual Unemployability (TDIU)

The RVSR is strongly encouraged to consider entitlement to TDIU when pension was previously awarded.

1. Ensure that when considering TDIU, the presumptive condition is the primary reason for the Veteran being unemployable.

2. If the RVSR has further questions, please e-mail VAVBAWAS/CO/NEHMER.

Example

The Veteran was granted entitlement to pension at 60 percent for IHD under disability code 7005. Under Nehmer review, VA determined that the Veteran is service-connected for IHD. Because IHD is the primary condition causing the Veteran to be unable to obtain or maintain gainful employment, award TDIU. Do not send VA Form 21-8940 because the evidence that VA would obtain from this form is already of record due to the pension claim.

NOTE: Prior to September 21, 1992, RVSRs were required to code all claims and noted claims (See Footnote 1 in Appendix 15).

NOTE: If a Nehmer claim involves multiple issues, only one rating decision is produced.

Claims for Service Connection

Claims for service connection may arise from:
- Informal claims
- Inferred claims
- Claims reasonably raised by VA
- For purposes of Nehmer review, a live pension claim is a claim for compensation

31

Issue(s)

Clearly state all issues of entitlement identified by the claimant or inferred based on the facts or circumstances of the claim. List the disability/disabilities and the current assigned evaluation(s). Also, specify any complications or other recognized herbicide-related conditions and the current assigned evaluation(s). See M21-1MR, Part IIl, iv.6.B.2.

Evidence and Evidentiary Basis

The Evidence section must be a clear and concise inventory of all evidence considered in arriving at the decision.

The evidence will include but is not limited to:

- Applicable dates, such as dates covered by service treatment records (STRs), identifying at least the month and year
- Private treatment reports
- Private hospitalization reports
- Information sources, such as the names of Department of Veterans Affairs (VA) and private medical facilities, private physicians, and other information sources,
- DD Form 214
- VA Form 21-526
- VA Form 21-534
- VA Form 21-530
- VA Form 21-601
- VA Form 21-4182, Application for Dependency and Indemnity Compensation or Death Pension, a supplemental attachment to Social Security application forms
- VA Examinations
- Social Security Administration Records
- Prior rating decision that denied service connection for the presumptive disability, unless this is an open claim
- Death Certificate/Autopsy Report
- All other information pertinent and related to the presumptive condition(s)

Decision

Clearly and concisely state the decision made on each issue or inferred issue. See M21-1MR, Part IIl, iv.6.C.9

Reasons for Decision

The rating decision must concisely cite and evaluate all evidence that is relevant and necessary to the determination. Clearly explain why the evidence is found to be persuasive or unpersuasive, and address all pertinent evidence relating to the presumptive condition(s).

NOTE: Nehmer decisions will be stand-alone documents as they will be reviewed without the claims folder by others as well as class counsel. Class counsel will not have the claims folder during their review, therefore, it is crucial all evidence pertinent to the presumptive condition(s) is listed and properly discussed in the decision.

Coding and Assigning a Percentage

The Cardiovascular System in the Rating Schedule was revised effective January 12, 1998. A grant of IHD prior to January 12, 1998, will require application of the Rating Schedule that was applicable on January 12, 1998. These evaluations are protected if there is no change in the condition AND the new regulation would result in a lower evaluation. However, if the new criteria provides for a higher evaluation, grant the entitlement effective the change in regulation. 38 U.S.C. § 1155; 38 C.F.R. § 3.114(a).

Special Monthly Compensation

Special monthly compensation entitlement must be considered as appropriate. Many times (S)1 (schedular housebound - single 100 percent and additional service connected conditions which combine to 60 percent), is in order when we grant an additional 100 percent under Nehmer (38 U.S.C. 1114(s) and 38 C.F.R. 3.350(i)).

Effective Date

The effective date of claims for service connection is the later of the date VA received the claim on which the prior denial was based or the date the disability arose.

For purposes of Nehmer IHD, PD, or HCL claims, the date a disability arose is the date VA had sufficient evidence or information to identify the existence of such a disease or, the evidence or information available was sufficient to “code” IHD, PD, or HCL as a disability pursuant to guidance regarding coding contained in the Veterans Benefits Adjudication Manual M21-1MR, and/or prior versions of such manual.

- Only death pension (NSC) was claimed or
- No distinction was made between death pension and DIC

VA Form 21-530, Application for Burial Benefits, must be considered for DIC if:

- SC was indicated on VA Form 21-530 and VA Form 21-534 was received within one year1
- VA‟s failure to provide VA Form 21-534 after receipt of VA Form 21-530 with SC indicated2
- In each instance, the effective date for the DIC benefits is the date the VA Form 21-530 was received3
- Receipt of attachment to Social Security Application, VA Form 21-4182, Application for Dependency and Indemnity Compensation or Death Pension, may establish the date of claim

38 C.F.R. § 3.150(b), Forms to be Furnished, receipt of notice of death must be considered if appropriate application form was not forwarded for execution by or on behalf of any dependent who has apparent entitlement to pension, compensation or DIC.

Evidence

For purposes of a Nehmer review, the standards for the evidence section of a rating decision for service-connected death do not differ from those of a rating decision for service connection. The evidence must show all the evidence pertaining to the claim identified for Nehmer review. Refer to the Evidence subsection of the Claims for Service Connection section for details on the requirements for Evidence.

Issue(s), Decision(s), and Reasons for Decision

For purposes of a Nehmer review, the standards for these elements (Issue, Decision, and Reasons for Decision) of a rating decision for service-connected death do not differ from those of a rating decision for service connection. Please refer to the subsection in the Claims for Service Connection section for guidance.

NOTE: A grant of DIC is appropriate when the presumptive condition is:

- Primary cause of death
- Secondary cause of death
- Contributory cause of death

Effective Date

The effective date for DIC claims must be one of the following dates:

- The date VA received the claim, or
- The first of the month of the Veteran‟s death, if filed within one year from the date of the Veteran‟s death.

A new period of DEA eligibility may accrue when the Veteran dies. As such, the issue of DEA eligibility may be considered twice in a single rating, once on the basis of retroactive entitlement when the Veteran was alive, and a second time for death benefits purposes.

See Appendix 7 for Rating Templates for DIC.

Claims for Service Connection and Service-Connected Death

Note that Nehmer claims may contain multiple issues, but that these issues are addressed in a single rating decision. All Nehmer claims involving claims for service connection and service-connected death must be addressed in one rating decision.

Coding Considerations

In order to generate live coding for a death case, you MUST use the “accrued” indicator in RBA2000. It is on the “Profile” screen (the screen on which you enter the jurisdiction and date of claim) on the left side, about halfway down. It will be accessible only for a death case. If you don‟t use the “accrued” indicator, the Master Record will allow you to enter all the historical live coding data, but will print only the death data.

Issue(s), Decision(s), and Reasons for Decision

For purposes of a Nehmer review, the standards for these elements (Issue, Decision, and Reasons for Decision) of a rating decision for service-connected death do not differ from those of a rating decision for service connection. Please refer to the subsection in the Claims for Service Connection section for guidance.

NOTE: After completion of the Rating, the Database should be updated to track all actions associated with a class member‟s claim.

AUTHORIZATION

The VSR and SVSR are responsible for assuring that the rating decision, award action(s), and notice of decision with appeal rights are accurate and properly prepared for all benefits. This includes live compensation claims, DIC claims, burial claims, and other retroactive benefits.

This section involves award processing for the following types of claims:

1) Live Veterans Claims
2) DIC Claims
3) Burial Claims

Prior to award input, the Nehmer database must be utilized to ensure previous actions associated with a class member‟s claim were completed. This will include re-verifying in-country RVN service and the initial document used to support the effective date shown in the rating decision. If any discrepancy is found, it will be brought to the attention of the RVSR that rated the claim for possible corrective action or concurrence.

A notification letter is not required if a memorandum for the record is prepared by the RVSR. Clear the pending EP. Update the Nehmer Database.

Live Veterans Claims

Prepare the award under the appropriate EP as instructed by the Nehmer Project Manager (Southern Area Office).

In situations where payment is not necessary, clear the EP and do not prepare an award. Examples of such instances include confirmed and continued rating decisions.

The following sections provide additional information on dependents, previous cost of living adjustments (COLAs), and withholding for military pay.

Dependents

If the Veteran‟s new combined evaluation for compensation is 30 percent or above, additional compensation is payable based on qualified dependents (to include Helpless Child).

If development for dependency was not completed prior to the rating decision, request the required evidence after processing the rating decision. Clear the EP in these situations.

Kicker / Public Law 101-508

Veterans that were in receipt of compensation benefits on December 1, 1990, did not receive a COLA until January 1, 1991. Public Law 101-508 reinstated the December 1, 1990, COLA. This was payable on March 1, 1992. This one-time payment was known as the “kicker.” VETSNET must be manually adjusted to account for the kicker.

Liesegang, et al v. Secretary of Veterans Affairs

On December 10, 2002, the US Court of Appeals for the Federal Circuit issued a decision in the case of Liesegang, et al v. Secretary of Veteran Affairs. The Court held that the correct effective date for our regulation adding Type 2 diabetes to the list of presumptive disabilities related to herbicide exposure is May 08, 2001, instead of July 9, 2001.

As a result of that decision, VA issued an automatic one-time adjustment to 9,340 Veterans granting an earlier payment date of June 1, 2001. The one time payment was made on August 4, 2003. In each adjusted case a notice was issued to the Veteran, POA, and RO. An additional 4,680 cases were manually reviewed. When reviewing the current Nehmer cases that may have previously involved Type 2 diabetes you must assure that this adjustment was actually made. This may require a thorough review of the claims folder. It is important that the Veteran gets paid correctly when entering the information into the prior payment field in VETSNET for retroactive awards.

Withholding for Military Pay

In claims that involve military retired pay, the authorization activity must ensure that all proper adjustments are made correctly. Verify the Veteran waived his or her military pay in lieu of compensation. This can be found on VA Form 21-526 or VA Form 21-651, Election of Comp in Lieu of Retired Pay or Waiver of Retired Pay to Secure Comp from VA.

NOTE: Prior to 1978, a signature block was not included on VA Form 21-526. A copy of Form 21-651 must be of record.

In some instances, the Veteran may have received separation, severance pay, or drill pay that must be adjusted. In these instances the authorization activity must assure that all adjustments are made properly.

NOTE: In some circumstances Veterans may receive full military retirement pay and VA compensation benefit payments.

NOTE: Retired pay rates will be obtained from DFAS database.

DIC Claims

The authorization activity must check all dependency information prior to awarding benefits. Only the proper claimant(s) can be paid.

Prepare the award under an appropriate EP as instructed by the Nehmer Project Manager (Southern Area Office). Be sure the payee number for the EP is appropriate for the claimant. For more information on payee codes, see M21-1 Part I, Appendix C.

Additional Allowances

When preparing the award, be sure to include any additional allowances that the surviving spouse may be entitled. For example, an additional allowance for:
-Dependents
- Total disability rating for a continuous period of eight years or more preceding death and the spouse married to the Veteran during the same time period

Death Prior to December 31, 1992

If the Veteran died prior to January 1, 1993, DIC is paid to a surviving spouse based on whichever of the following provisions provides the greater benefit:

- 38 U.S.C. § 1311a(3), which is based on the Veteran's pay grade, or
- 38 U.S.C. § 1311a(1) and 38 U.S.C. § 1311a(2), which is based on the basic rate of DIC and any additional allowance payable because the Veteran was rated as totally disabled for at least eight continuous years and married to the surviving spouse for the same period of time

The pay grade for all Veterans who died prior to December 31, 1992, must be verified. Pay grade may be found on the DD Form 214 or other service documents.

A verified pay grade code is not required on:

- Awards of DIC to children or parents, or
- Awards based on a Veteran's death after December 31, 1992

Withholding for SBP Payments

In claims that involve SBP, the authorization activity must assure that all proper adjustments are made correctly. Under a recent Federal Circuit decision, DFAS cannot deduct DIC payments from monthly SBP annuities, if the annuitant is entitled to both DIC and SBP benefits, and has remarried after age 57.

NOTE: SBP payments may be obtained from DFAS database.

Remarriage of the Surviving Spouse

The Surviving Spouse may have remarried after the death of the Veteran. Please review M21-1MR, IV.III.3.F.23, General Information on the Effect of a Surviving Spouse's Remarriage, for additional guidance.

Month of Death Payment

Before awarding the month of death payment, verify that the surviving spouse has not received this payment by using the Payment History Inquiry Screen in Corporate and a review of the claims folder.

Consideration of VA Form 21-4182, Application for Dependency and Indemnity Compensation or Death Pension, must be recognized as a claim for VA death benefits (See M21-1MR IV.iii.3.A.4 and 38 C.F.R. § 3.153).

VA Form 21-4182 constitutes an initial claim for any or all of the death benefits:

-DIC
- Death pension, and/or
- Accrued benefits.

Additional information may be found M21-1MR III.ii.2.C.14.b.

Burial Claims

Before awarding monetary burial benefits the authorization activity must verify all
evidence is of record.

Prepare the award under an appropriate EP as instructed by the Nehmer Project
Manager (Southern Area Office).

The following sections provide additional information on dependents, previous
cost of living adjustments, and withholding for military pay.

Burial Claims Prior to the Current December 1, 2001, Rate

Please be aware that service connected burial payments were less than $2000
prior to December 1, 2001. See the table below for a list of prior rates and their
effective dates.

* The SC burial amount was increased on December 1, 2001, and is effective for deaths that occurred on or after September 11, 2001.

Prior Payments of NSC Burial

Check the claims folder for any prior payments of NSC burial. This amount must be deducted from the total amount for service connected benefits payable.

Retroactive Benefits

Prepare the award under an appropriate EP as instructed by the Nehmer Project Manager (Southern Area Office). Ensure that the correct rates and total retroactive amounts have been calculated correctly. If multiple payees exist, prepare awards using different payee codes, dividing the total amount equally.

Award Annotation

The VSR must annotate the award with “Nehmer Retroactive payment based on [the name of new presumptive condition]” in the remarks section of the award printout.

Notification Letter

Use PCGL to generate the notification letters. Be sure to suppress the BDN- generated letters as only locally generated letters may be issued. Examples of the notification letters for live cases and death cases can be found in Appendix 10.

For burial claims, use the standard burial letter found in PCGL to generate the notification letters. This letter should be merged with the death letter, when there was a claim for DIC.

Verify the letter contains a calculation of the retroactive amount and be sure to include all ancillary benefits that the Veteran or his/her dependents may be entitled. Award and denial letters must include:

- The decision made
- The monthly VA rates
- The applicable effective dates
- Any benefits being withheld and the reason for withholding benefits
- Estimated retroactive benefit
- Appellate rights of the claimant
- Information about any additional benefits or entitlements the claimant may be due

After award authorization, the letters must be scanned into Virtual VA. For more information on using Virtual VA, see the Virtual VA User Guide.

Sending Documents to OGC

In accordance with the court order, a copy of the Payment History Inquiry Screen in Corporate must be submitted when requested by OGC. Please refer to Appendix 6 for contact information.

APPENDICES

Appendix 1 – List of Presumptive Conditions in 38 C.F.R. § 3.816

The following is a list of conditions presumptively associated with herbicide exposure and the dates the regulations governing the presumptions became effective, as found in 38 C.F.R. § 3.816 (b)(2):

C&P Service has initiated a program to collect data on Vietnam naval operations for the purpose of providing regional offices with information to assist with development in Haas related disability claims based on herbicide exposure from Navy Veterans. To date, we have received verification from various sources showing that a number of offshore “blue water” naval vessels conducted operations on the inland “brown water” rivers and delta areas of Vietnam. We have also identified certain vessel types that operated primarily or exclusively on the inland waterways. The ships and dates of inland waterway service are listed below. If a Veteran‟s service aboard one of these ships can be confirmed through military records during the time frames specified, then exposure to
herbicide agents can be presumed without further development.

All vessels with the designation LST [Landing Ship, Tank] during their entire tour [WWII ships converted to transport supplies on rivers and serve as barracks for brown water Mobile Riverine Forces]

All vessels with the designation LCVP [Landing Craft, Vehicle, Personnel] during their entire tour

All vessels with the designation PCF [Patrol Craft, Fast] during their entire tour [Also called Swift Boats, operating for enemy interdiction on close coastal waters]

All vessels with the designation PBR [Patrol Boat, River] during their entire tour [Also called River Patrol Boats as part of the Mobile Riverine Forces operating on inland waterways and featured in the Vietnam film “Apocalypse Now”]

The National Archives and Records Administration (NARA) has confirmed that the Navy destroyer USS Ingersoll (DD 652) traveled into the inland waterways of RVN on October 24 and 25, 1965. Concede exposure to herbicides for crewmembers that served aboard the USS Ingersoll on these dates.

If personnel records are unavailable, or do not confirm a specific shipboard assignment during this timeframe, send a request for a review of NARA records to C&P Service via e-mail at VAVBAWAS/CO/211/AGENTORANGE. This request should include the Veteran's:

- Name
- Date of birth
- VA claim number
- Social Security number (SSN), and
- Service number, if different than SSN

Claims Based on Service Aboard Ships Offshore the RVN

When a Veteran claims exposure to herbicides during service aboard a Navy or Coast Guard ship that operated on the offshore waters of the RVN, establish exposure on a presumptive basis if:

- Evidence shows the ship
-- Docked on the shores of the RVN, or
-- Operated temporarily on the RVN inland waterways

- Evidence places the Veteran onboard the ship at the time the ship docked on the shore or operated in inland waterways, and

- If the Veteran claims the ship docked on the shore, the Veteran has stated that he/she went ashore after the ship docked

IMPORTANT: In all cases where a Veteran claims exposure to herbicides during service aboard a ship in offshore waters, regional offices should place a copy of the U.S. Army and Joint Services Records Research Center's (JSRRC's) memorandum shown in Appendix 3 in the Veteran's claim folder. This document will:

- Substitute for individual inquiries to the Compensation and Pension Service's Agent Orange mailbox and to the JSRRC, and
- Establish that the JSRRC has no evidence to support a claim of herbicide exposure during shipboard service

NOTE:
- Service aboard a ship that anchored in an open deep-water harbor, such as Da Nang, Vung Tau, or Cam Ranh Bay, along the RVN coast does not constitute inland waterway service or qualify as docking to the shore and is not sufficient to establish presumptive exposure to herbicides. Evidence of shore docking is required in order to concede the possibility that the Veteran's service involved duty or visitation in the RVN

- Veterans who served aboard large ocean-going ships that operated on the offshore waters of the RVN are often referred to as "blue water" Veterans because of the blue color of the deep offshore waters. They are distinguished from "brown water" Veterans who served aboard smaller river patrol and swift boats that operated on the brown-colored rivers, canals, estuaries, and delta areas making up the inland waterways of the RVN

- Brown water Navy and Coast Guard Veterans receive the same presumption of herbicide exposure as Veterans who served on the ground in the RVN

Appendix 3 – Naval and Coast Guard Development

The current development and due process requirements for Navy and Coast Guard claims include sending a request for research to both the C&P Service Agent Orange Mailbox and JSRRC for verification exposure. In order to expedite the resolution of these claims, JSRRC provided a document for inclusion in the Veteran‟s file.

This document substitutes as a response from the C&P Service Agent Orange Mailbox as well JSRRC and explains that there is no available evidence to support a claim of herbicide exposure aboard a Navy or Coast Guard ship during Vietnam. It will serve as a final JSRRC response in claims where the Veteran alleges exposure based on:
1) loading herbicide agents aboard a naval ship for transportation to Vietnam,
(2) serving aboard a ship that transported, stored, used, or tested herbicide agents, and
(3) working on shipboard aircraft that flew over Vietnam or equipment that was used in Vietnam.

SUBJECT: Joint Services Records Research Center Statement on Research Findings Regarding Navy and Coast Guard Ships During the Vietnam Era

1. In the course of its research efforts, the JSRRC has reviewed numerous official military documents, ships histories, deck logs, and other sources of information related to Navy and Coast Guard ships and the use of tactical herbicide agents, such as Agent Orange, during the Vietnam Era.

2. To date, the JSRRC has found no evidence that indicates Navy or Coast Guard ships transported tactical herbicides from the United States to the Republic of Vietnam or that ships operating off the coast of Vietnam used, stored, tested, or transported tactical herbicides. Additionally, the JSRRC cannot document or verify that a shipboard veteran was exposed to tactical herbicides based on contact with aircraft that flew over Vietnam or equipment that was used in Vietnam.

3. Therefore, the JSRRC can provide no evidence to support a veteran's claim of exposure to tactical herbicide agents while serving aboard a Navy or Coast Guard ship during the Vietnam Era.

- From the C&P Service Intranet Home Page, click on “Stressor Verification
Site” which is located under the Rating Job Aids section
- On the “Stressor Verification - General Information” page, click on
“General 1942-2002 APO-FPO Files”
- After clicking on the link, the PDF will load all of the FPO-APO files.
- The Vietnam FPO-APO addresses begin on page 4999

The following APO‟s have been verified by the Military Postal Service Agency
(MPSA) as having been used for delivery to Vietnam.

A hospital or medical treatment report with one of the approved APO codes indicates that the Veteran was seen or treated in an RVN.

Appendix 5 – Workflow for Processing Nehmer Claims

NOTE: TO VBN USERS: THIS IS A GRAPH WHICH I CANNOT DO HERE.

Is the claimant a Nehmer class member?
Does the Claimant Have:
In-country Vietnam Service
Diagnosis
Prior Claim
No -
Not a Nehmer
class member
Yes -
Nehmer class member
Is medical or service
development required
Live/death
VSR/RVSR determines
medical evidence is
sufficient to rate
Can
VSR identify all
claimant(s) and
current
address No to
any
Evidence
received
Annotate the claims file
SVSR reviews and
approves rating and
decision notice
Yes to both
No
Death only - No
prior live claim(s)
on/after 9/25/85
VSR reviews all
prior ratings for
earlier effective
date or initial grant
VSR reviews file
for 21-534 (DIC)
and/or 21-530
(burial)
If there was a 530,
was development
done for a 534
Consider SC death
Consider SC death
VSR reviews:
 File
 Death certificate
 Dependency information
 Income information
 Proper claimant
 Paid receipt of burial expenses
VSR/RVSR
determines
evidence of record
is sufficient to rate
Yes and 534
was sent back
RVSR prepares
memo for the
record
Not a Nehmer
class member
No
Yes and 534 was
not sent back
RVSR prepares rating to address:
 Live vs. death issues
 New AO presumptions
 Any deficiency for other AO
presumptions
 All rating deficiencies
 Any pending issues not
related to AO presumptives
 Effective date
VSR/RVSR reviews claims
and determines required
development - verify in-
country Vietnam service
and clarifies diagnosis and
other information, i.e.
dependency, parent, SBP,
retired pay, location of
eligible payees, death
certificate, current medical
and burial receipts.
30 day suspense and no
limit imposed for
submission of evidence
Yes No
RVSR second signature
review of rating
VSR prepares decision notice
that includes:
 Appeal rights
 Ancillary information
 Amount of retro
VSR prepares decision
notice with appeal rights
VSR:
 Prepares decision notice
addressed to estate of class
member and/or potential
claimant(s) identified in
claims file
 Inquires about other potential
claimant(s)
 Amount of retro
 30 day suspense
 No limit imposed for
submission of evidence
Yes
At end of 30 day suspense
or receipt of required
evidence, VSR sends to
RVSR for rating
preparation. No limit
imposed for submission of
evidence

Defense Finance and Accounting Service – SBP ONLY
Method Contact Information
Telephone - SBP ONLY 216-522-6393
Separation, severance and retired pay contact
information will be provided at a later date.

Mr./Ms. [enter full name], your records reflect that you are a Veteran who served in the [enter military branch] from [enter date] to [enter date]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson‟s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA records indicate that you previously filed a claim for [insert name of new presumptive condition] and were subsequently denied. A special review of your claims file was mandated by federal court order in Nehmer v. Department of Veterans Affairs. Based on our review of the evidence listed below, we have made the following decision(s) in your case.

DECISION

1. Service connection for [insert new presumptive condition here] associated with herbicide exposure is granted with a [percentage] percent evaluation, effective [insert date of receipt of the Veteran‟s initial claim for service connection for this condition].

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

1. Service connection is granted for [insert presumptive diagnosis], for purposes of entitlement to retroactive benefits.

VA has confirmed that you had in-country service in the Republic of Vietnam based on [insert evidence here].

Medical evidence from [hospital, doctor, laboratory results] in the record indicates a diagnosis of [diagnosis] on [date]. [Reason for effective date].

You claimed service connection for [diagnosis] on [insert date of claim]. Service connection for [diagnosis] was denied by a rating decision dated, [insert date of decision] because [diagnosis] was not incurred or aggravated during military service, nor was it present to a degree of 10 percent within one year of your discharge from active duty.

Subsequently, [diagnosis] was added recently to the list of disabilities recognized as being related to herbicide exposure. As such, service connection for [diagnosis] is now granted because it is presumptively related to your military service. The effective date of service connection for [diagnosis] is [insert date of receipt of claim], the date your original claim for service connection for [diagnosis] was received.

[Insert paragraph for rating of the new presumptive condition and include an
explanation of the percentage assigned for the condition, as well as the
requirements for achieving the next higher percentage level.]
[Include a thorough discussion of relevant medical evidence used to assign the
rating, including any secondary conditions.]

Example Rating Decision for Live Compensation with Prior Grant

INTRODUCTION

Mr./Ms. [enter full name], your records reflect that you are a Veteran who served in the [enter military branch] from [enter date] to [enter date]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson‟s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA records indicate that service connection was previously granted for [insert issue/diagnosis] and [insert type of benefits] benefits were paid.

VA records indicate that you previously filed a claim for [insert name of new presumptive condition(s)] and were subsequently denied. A special review of your claims file was mandated by federal court order in Nehmer v. Department of Veterans Affairs. Based on our review of the evidence listed below, we have made the following decision(s) in your case.

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias,
such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in Republic of Vietnam.

1. Service connection for [insert presumptive disability], for purposes of entitlement to retroactive benefits.

VA has confirmed that you had in-country service in the Republic of Vietnam based on [insert evidence here].

Medical evidence from [hospital, doctor, laboratory results] in the record indicates a diagnosis of [insert presumptive disability] on [date].

You claimed service connection for [insert disability] on [insert date of claim]. ervice connection for [disability] was established by a rating decision dated, [insert date of decision] because [insert basis for grant].

Subsequently, [insert presumptive disability] was added recently to the list of disabilities recognized as being related to herbicide exposure. As such, service connection is now granted because it is presumptively related to your military service. The effective date of service connection for [insert presumptive disability] is [insert date of receipt of claim], the date your original claim for service connection for [insert presumptive disability] was received.

[Insert paragraph for rating of the new presumptive condition and include an explanation of the percentage assigned for the condition, as well as the requirements for achieving the next higher percentage level.]

Example Rating Decision for Live Compensation Denial

INTRODUCTION

Mr./Ms. [full name], your records reflect that you are a Veteran who served in the [military branch] from [date] to [date]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson’s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA records indicate that you previously filed a claim for [insert name of new presumptive condition] and were subsequently denied. A special review of your claims file was mandated by federal court order in Nehmer v. Department of Veterans Affairs. Based on our review of the evidence listed below, we have made the following decision(s) in your case.

DECISION

1. Service connection for [insert presumptive disability], for purposes of -entitlement to retroactive benefits is not granted.

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias,
such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

1. Service connection for [insert presumptive disability], for purposes of entitlement to retroactive benefits.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

Medical evidence from [hospital, doctor, laboratory results] in the record indicates a diagnosis of [insert presumptive disability] on [date]. You claimed service connection for [insert presumptive disability] on [insert date of claim]. Service connection for [enter presumptive disability] was denied by a rating decision dated, [insert date of decision] because [insert reason(s) for denial].

The denial of your claim for service connection for [insert presumptive disability] is confirmed, because [insert reason(s) for confirming denial.

[Include an explanation for the denial here]

Example Rating Decision for Service-Connected Death Grant with No Prior
Grant

INTRODUCTION

VA‟s records reflect that [full name] was a Veteran who served in the [military branch] from [date] to [date]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson‟s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA‟s records indicate that you previously filed a claim for your [DIC claimant’s relationship]‟s death as a result of [insert presumptive disability] and were subsequently denied. A special review of the Veteran‟s claims file was mandated by federal court order in Nehmer v. Department of Veterans Affairs. Based on our review of the evidence listed below, we have made the following decision(s) in this case.

DECISION

1. Service connection for the cause of death is granted.
2. Basic eligibility to Dependents‟ Educational Assistance is established effective [insert date].

EVIDENCE

- DD Form 214
- VA Form 21-534, Application for Dependency and Indemnity Compensation, received on [date]
- Death certificate
- Medical Evidence [Medical Evidence may include, but is not limited to 1) diagnosis; 2) date of diagnosis; 3) date of death; 4) cause of death; and autopsy report.]

*Note to RVSR: Always verify that the Veteran filed no claim during his/her lifetime. Also verify whether a 21-530, Application for Burial Benefits has been submitted.

REASONS FOR DECISION

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias,
such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

1. Service connection for the cause of the Veteran‟s death, for purposes of entitlement to retroactive benefits.

VA has confirmed that the Veteran had in-country service in the Republic of Vietnam based on [insert evidence here].

During the lifetime of the Veteran, [he/she] did not submit a claim for benefits based on [insert presumptive disability].

On [date] a claim for service connected death benefits as a result of the Veteran‟s death was received. On [date], this claim was denied because, at that time, [insert presumptive disability] was not found to have been incurred or aggravated during military service, nor was it present to a degree of 10 percent within one year of the Veteran‟s discharge from active duty.

On [date] the Veteran died and the cause of death was recorded as [cause of death, including contributory causes, if relevant].

Subsequently, [insert presumptive disability] was added recently to the list of disabilities recognized as being related to Agent Orange exposure. As such, service connection for the cause of the Veteran‟s death is now granted, effective from [date]. [Reason for effective date]

NOTE: [Insert only if a VAF 21-530 is not in file-Please send VA Form 21-530, Application for Burial Benefits to surviving spouse.]

Eligibility to Dependents‟ Educational Assistance is derived from a Veteran who has a permanent and total service-connected disability; or a permanent and total disability was in existence at the time of death; or the Veteran died as a result of a service-connected disability. Also, eligibility exists for a serviceperson who died in service. Basic eligibility to Dependents‟ Education Assistance is granted and is effective from [insert date], because the Veteran‟s death is presumptively related to military service.

[Insert the reasons for the effective date here]

Example Rating Decision for Service-Connected Death Grant with Prior Grant (claim received within one year of Veteran’s death)

INTRODUCTION

VA‟s records reflect that [full name] was a Veteran who served in the [military branch] from [date] to [date]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson‟s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA‟s records indicate that you previously filed a claim for your [DIC claimant’s relationship]‟s death as a result of [insert name of new presumptive condition]. A special review of the Veteran‟s claims file was mandated by federal court order in Nehmer v. Department of Veterans Affairs. Based on our review of the evidence listed below, we have made the following decision(s) in this case.

DECISION

1. An earlier effective date is granted for the service-connected cause of death.
2. An earlier effective date for eligibility to Dependents‟ Educational Assistance is established.

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias,
such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

1. An earlier effective date is granted for the service-connected cause of death.

VA has confirmed that the Veteran had in-country service in the Republic of Vietnam based on [insert evidence here].

On [insert date of diagnosis], medical evidence in the record indicates your [insert claimant‟s relationship] was diagnosed with [insert presumptive disability]. On [date] your [insert claimant‟s relationship] died and the cause of death was recorded as [cause of death, including contributory causes, if relevant].

On [date of award and notice letter], we granted benefits for your DIC claim, with an effective date of [insert effective date for 534], the date your DIC claim was received.

Subsequently, [insert presumptive diagnosis] was added to the list of disabilities recognized as being related to Agent Orange exposure. As such, an earlier effective date for DIC benefits as a result of your [insert claimant‟s relationship]‟s death is now granted. The effective date is [insert earlier effective date] [Reason for earlier effective date].

Eligibility to Dependents‟ Educational Assistance is derived from a Veteran who has a permanent and total service-connected disability; or a permanent and total disability was in existence at the time of death; or the Veteran died as a result of a service-connected disability. Also, eligibility exists for a serviceperson who died in service. Basic eligibility to Dependents‟ Education Assistance is granted and is effective from [date].

VA‟s records reflect that [full name] was a Veteran who served in the [military branch] from [date] to [date]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson‟s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA‟s records indicate that there was a claim previously filed for your [DIC claimant‟s relationship]‟s death as a result of [insert name of new presumptive condition]. A special review of the Veteran‟s claims file was mandated by federal court order in Nehmer v. Department of Veterans Affairs. Based on our review of the evidence listed below, we have made the following decision(s) in this case.

DECISION

1. Service connection for the cause of death is granted.
2. Basic eligibility to Dependents‟ Educational Assistance is established.

EVIDENCE

- DD Form 214
- VA Form 21-534, Application for Dependency and Indemnity Compensation (DIC), received on [insert date 534 received]
- Death certificate
- Medical Evidence [Medical Evidence may include, but is not limited to 1) diagnosis; 2) date of diagnosis; 3) date of death; 4) cause of death; and autopsy report.]

REASONS FOR DECISION

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

1. Service connection for the cause of the Veteran‟s death, for purposes of entitlement to retroactive benefits.

VA has confirmed that the Veteran had in-country service in the Republic of Vietnam based on [insert evidence here].

On [insert date VA Form 21-534 received] you filed a claim for non service- connected pension benefits. Medical evidence in the record indicates a diagnosis of [insert presumptive disability] on [insert date of diagnosis]. On [date] the Veteran died and the cause of death was recorded as [cause of death, including contributory causes, if relevant].

Subsequently, [insert presumptive disability] was added recently to the list of disabilities recognized as being related to Agent Orange exposure. As such, service connection for cause of death is now granted. The effective date is [date VA Form 21-534 claim was received], the date your claim for non service- connected benefits was submitted.

Eligibility to Dependents‟ Educational Assistance is derived from a Veteran who has a permanent and total service-connected disability; or a permanent and total disability was in existence at the time of death; or the Veteran died as a result of a service-connected disability. Also, eligibility exists for a serviceperson who died in service. Basic eligibility to Dependents‟ Education Assistance is granted and is effective from [date].

Example Rating Decision for Service-Connected Death Confirmed and
Continued

INTRODUCTION

VA‟s records reflect that [full name] was a Veteran who served in the [military branch] from [date] to [date]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson‟s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA‟s records indicate that you previously filed a claim for your [DIC claimant‟s relationship]‟s death as a result of [insert name of new presumptive condition] and were subsequently denied. A special review of the Veteran‟s claims file was mandated by federal court order in Nehmer v. Department of Veterans Affairs. Based on our review of the evidence listed below, we have made the following decision(s) in this case.

DECISION

1. The prior decision regarding service connection for cause of death is confirmed and no change is warranted for that prior denial under the provisions of the court‟s orders in Nehmer.

EVIDENCE

- DD Form 214
-VA Form 21-534, Application for Dependency and Indemnity Compensation, received on [date]
- VA Form 21-530, Application for Burial Benefits was received on [insert date]
- Death certificate
- Medical Evidence [Medical Evidence may include, but is not limited to 1) diagnosis; 2) date of diagnosis; 3) date of death; 4) cause of death; and autopsy report.]
- Decision dated [insert date of decision] denied service connection for cause of death

REASONS FOR DECISION

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias,
such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

1. Service connection for the cause of the Veteran‟s death, for purposes of entitlement to retroactive benefits.

VA has confirmed that the Veteran had in-country service in the Republic of Vietnam based on [insert evidence here].

During the lifetime of your [DIC claimant‟s relationship-husband, son, spouse, father, etc], [he/she] did not submit a claim for benefits based on [insert disability shown as cause of death].

On [date] a claim for service connected death benefits as a result of his/her death was received. The date of death is [insert date] and the cause of death was recorded as [cause of death, including contributory causes, if relevant]. A rating dated [insert date], denied your DIC claim.

The denial of your claim for service-connected death is confirmed and no change is warranted under the provisions of the court‟s orders in Nehmer.

Example Rating Decision for Service-Connected Death Grant and Retroactive Compensation

INTRODUCTION

VA‟s records reflect that [insert full name of Veteran] was a Veteran who served in the [insert name of military branch in which Veteran served] from [insert date service began] to [insert date of discharge]. The Secretary of the Department of Veterans Affairs (VA) has established that Ischemic Heart Disease, Parkinson‟s Disease, Hairy Cell Leukemia and other Chronic B-cell Leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions.

VA‟s records indicate that your [insert DIC claimant‟s relationship, i.e.- husband, father, etc] previously filed a claim for [insert name of new presumptive disability] and was subsequently denied. A special review of your [survivor‟s relationship]‟s claims file was mandated by federal court order in Nehmer v. Department of Veterans Administration. Based on our review of the evidence listed below, we have made the following decision(s) in this case.

DECISION

1. Service connection for [insert presumptive disability] associated with herbicide exposure is granted with a [insert percentage] percent evaluation, effective [insert date of receipt of the Veteran‟s initial claim for service connection for this condition].
2. Service connection for the cause of death is granted.
3. Basic eligibility to Dependents‟ Educational Assistance is established.

EVIDENCE

- DD Form 214
- VA Form 21-526, Veteran‟s Application for Compensation or Pension, received on [insert date of receipt of the Veteran‟s original claim for service connection for this condition].
- Other information that creates a claim (informal, inferred, implied or a potential claim)
- VA examination dated [insert date of exam]
- Other Medical Evidence (private, SSA, treatment reports)
- Service Treatment Records
- Decision dated [insert date of decision], denied service connection for [insert presumptive disability]
- VA Form 21-534, Application for Dependency and Indemnity Compensation, received on [insert date claim received]
- Death certificate
- VA Form 21-530, Application for Burial Benefits received on [insert date claim received]
- Decision dated [insert date of rating], denied service connected death for [insert presumptive disability]

REASONS FOR DECISION

Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin‟s lymphoma, soft tissue sarcoma, Hodgkin‟s disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson‟s disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia.

For purposes of this review, Vietnam Veterans had in-country service in the Republic of Vietnam.

1. Service connection for [insert presumptive disability], for purposes of entitlement to retroactive benefits.

VA has confirmed that the Veteran had in-country service in the Republic of Vietnam based on [insert evidence here].

Medical evidence in the record indicates a diagnosis of [insert presumptive disability] on [date]. The Veteran claimed service connection for [insert presumptive disability] on [insert date of claim]. Service connection for [insert presumptive disability] was denied by a rating decision dated, [insert date of decision] because [insert presumptive disability] was not incurred or aggravated during military service, nor was it present to a degree of 10 percent within one year of the Veteran‟s discharge from active duty.

Subsequently, [insert presumptive disability] was added recently to the list of disabilities recognized as being related to herbicide exposure. As such, service connection for [insert presumptive disability] is now granted because it is presumptively related to the Veteran‟s military service. The effective date of service connection for [insert presumptive disability] is [insert date of receipt of claim], the date the Veteran‟s original claim for service connection for [insert presumptive disability] was received.

[Insert paragraph for rating of the new presumptive condition and include an explanation of the percentage assigned for the condition, as well as the requirements for achieving the next higher percentage level.]

2. Service connection for the cause of the Veteran‟s death, for purposes of entitlement to retroactive benefits.

On [date] the Veteran died and the cause of death was recorded as [cause of death, including contributory causes, if relevant]. On [date] a claim for service connected death benefits as a result of the Veteran‟s death was filed. On [date], this claim was denied because, as was found in the previous denial of the Veteran‟s claim, [insert presumptive disability] was not found to have been incurred or aggravated during military service, nor was it present to a degree of 10 percent within one year of the Veteran‟s discharge from active duty.

Subsequently, [insert presumptive disability] was added recently to the list of disabilities recognized as being related to herbicide exposure. As such, service connection for the cause of the Veteran‟s death is now granted, because it is presumptively related to the Veteran‟s military service. The effective date of service connection for the Veteran‟s death is [insert date of receipt of DIC claim], the date your original claim for service connection for your [survivor‟s relationship] death was received.

Eligibility to Dependents‟ Educational Assistance is derived from a Veteran who has a permanent and total service-connected disability; or a permanent and total disability was in existence at the time of death; or the Veteran died as a result of a service-connected disability. Also, eligibility exists for a serviceperson who died in service. Basic eligibility to Dependents‟ Education Assistance is granted and is effective from [date].

************************
Example Memorandum for the Record for No Vietnam Service

NOTE TO VBN USERS: THIS IS IN A BOX FORM BUT I’M UNABLE TO MAKE ONE.

NEHMER
MEMORANDUM FOR THE RECORD
Department of Veterans
Affairs
POA

Date of
Memorandum

Veteran’s Name

Resource Center

VA Employee Name

VA File Number

ISSUE: No Vietnam Service

A systematic review of the Veteran‟s claims folder has been conducted in accordance with Nehmer v. U.S. Department of Veterans Affairs, which requires the payment of retroactive benefits to certain Nehmer class members. This case was identified as a potential Nehmer-class case based on the addition of Ischemic Heart Disease, Parkinson‟s Disease, and B-cell/Hairy cell leukemias to the list of diseases presumptively associated with exposure to certain herbicide agents. Entitlement to potential retroactive benefits applies to all cases wherein VA received a claim for benefits, or wherein VA denied benefits, on or after September 25, 1985, and before the date VA publishes the final regulation adding the new disabilities to the list of diseases presumptively associated with herbicide exposure in Vietnam.

VA has confirmed that the Veteran did not have service in the Republic of Vietnam as defined by law. In the absence of any conclusive evidence that the Veteran served in the Republic of Vietnam, or was otherwise exposed to herbicides used in the Republic of Vietnam during military service, further review under Nehmer is not required. If VA receives any documentation that confirms that the Veteran did perform duty in the Republic of Vietnam, then entitlement to benefits under the Nehmer court order will be reconsidered.

[User Input - A detailed explanation regarding why the individual is not a class member is required. The explanation must be sufficient in detail for the reviewer to undertake a clear analysis as to why the case does not qualify for Nehmer readjudication.]

Name (Rating Specialist/DRO)

Name (Rating Specialist/DRO)

****************************
Example Memorandum for the Record for No Diagnosis

NOTE TO VBN USERS: THIS IS IN A BOX FORM BUT I’M UNABLE TO MAKE ONE.

NEHMER
MEMORANDUM FOR THE RECORD
Department of Veterans
Affairs
POA

Date of
Memorandum

Veteran’s Name

Resource Center

VA Employee Name

VA File Number

ISSUE: No Diagnosis

A systematic review of the Veteran‟s claims folder has been conducted in accordance with Nehmer v. U.S. Department of Veterans Affairs, which requires the payment of retroactive benefits to certain Nehmer class members. This case was identified as a potential Nehmer-class case based on the addition of Ischemic Heart Disease, Parkinson‟s Disease, and B-cell/Hairy cell leukemias to the list of diseases presumptively associated with exposure to certain herbicide agents. Entitlement to potential retroactive benefits applies to all cases wherein VA received a claim for benefits, or wherein VA denied benefits, on or after September 25, 1985, and before the date VA publishes the final regulation adding the new disabilities to the list of diseases presumptively associated with herbicide exposure in Vietnam.

VA has confirmed that the Veteran was not diagnosed with one of the Nehmer-related disabilities and that no evidence indicating the existence of such disability is present in the Veteran‟s VA claim file between September 25, 1985, and the date VA published the final regulation adding the new disabilities to the list of diseases presumptively associated with herbicide exposure in Vietnam. In the absence of such evidence, further review under Nehmer is not required. If VA receives any documentation that confirms that the Veteran was diagnosed with a Nehmer-related disability, then entitlement to benefits under the Nehmer court order will be reconsidered.

[User Input - A detailed explanation regarding why the individual is not a class member is required. The explanation must be sufficient in detail for the reviewer to undertake a clear analysis as to why the case does not qualify for Nehmer readjudication.]

Name (Rating Specialist/DRO)

Name (Rating Specialist/DRO)

*****************************
Example Memorandum for the Record for No Claim

NOTE TO VBN USERS: THIS IS IN A BOX FORM BUT I’M UNABLE TO MAKE ONE.

NEHMER
MEMORANDUM FOR THE RECORD
Department of Veterans
Affairs
POA

Date of
Memorandum

Veteran’s Name

Resource Center

VA Employee Name

VA File Number

ISSUE: No Prior Claim

A systematic review of the Veteran‟s claims folder has been conducted in accordance with Nehmer v. U.S. Department of Veterans Affairs, which requires the payment of retroactive benefits to certain Nehmer class members. This case was identified as a potential Nehmer-class case based on the addition of Ischemic Heart Disease, Parkinson‟s Disease, and B-cell/Hairy cell leukemias to the list of diseases presumptively associated with exposure to certain herbicide agents. Entitlement to potential retroactive benefits applies to all cases wherein VA received a claim for benefits, or wherein VA denied benefits, on or after September 25, 1985, and before the date VA publishes the final regulation adding the new disabilities to the list of diseases presumptively associated with herbicide exposure in Vietnam.

VA has confirmed that the Veteran/Widow did not file a claim for benefits nor was denied a claim for benefits, as defined under Nehmer between September 25, 1985, and the date VA published the final regulation adding the new disabilities to the list of diseases presumptively associated with herbicide exposure in Vietnam. In the absence of such evidence, further review under Nehmer is not required.

[User Input - A detailed explanation regarding why the individual is not a class member is required. The explanation must be sufficient in detail for the reviewer to undertake a clear analysis as to why the case does not qualify for Nehmer readjudication.]

The patient/Veteran has applied to the U. S. Department of Veterans Affairs for disability
benefits. Please complete this Questionnaire, which we need for review of the application.

1. Diagnosis: Does the Veteran have ischemic heart disease (IHD)? Yes No
(If no, please skip to the signature section.)
Diagnosis: ___________________________________ Date of diagnosis: ____________________
NOTE: IHD includes but is not limited to acute, sub-acute and old myocardial infarction;
atherosclerotic cardiovascular disease including coronary artery disease, including coronary
spasm and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina. IHD does
not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral
vascular disease or stroke.

3. Congestive Heart Failure (CHF):
Does the Veteran have chronic CHF? Yes No
More than one episode of acute CHF in the past year? Yes No
Treatment facility/date of most recent episode of CHF: ___________________________________

4. Cardiac Functional Assessment:

a. Level of METs the Veteran can perform as shown by diagnostic exercise testing: ___________

b. If METs testing was not completed because it is not required as part of Veteran’s
treatment plan, complete the following METs test based on the Veteran’s responses:

Lowest level of activity at which the Veteran reports symptoms (check all symptoms that
apply)
dyspnea fatigue angina dizziness syncope
(1-3 METs) This METs level has been found to be consistent with activities such as
eating, dressing, taking a shower, slow walking (2 mph) for 1-2 blocks

(>3-5 METs) This METs level has been found to be consistent with activities such as
light yard work (weeding), mowing lawn (power mower), brisk walking
(4 mph)
(>5-7 METs) This METs level has been found to be consistent with activities such as
golfing (without cart), mowing lawn (push mower), heavy yard work
(digging)
(>7-10 METs) This METs level has been found to be consistent with activities such as
climbing stairs quickly, moderate bicycling, sawing wood, jogging (6
mph)
The Veteran denies experiencing above symptoms with any level of physical activity

NOTE: VA may request additional medical information, including additional examinations if
necessary to complete VA‟s review of the Veteran‟s application.
FOR INTERNAL VA USE ONLY

******************************
Parkinson‟s Disease VAE Template

Parkinson’s Disease
Disability Benefits Questionnaire
Name of patient/Veteran: _____________________________________SSN: ____________________
The patient/Veteran has applied to the U. S. Department of Veterans Affairs for disability
benefits. Please complete this Questionnaire, which we need for review of the application.

1. Diagnosis: Does the Veteran now have or has he/she ever been diagnosed with
Parkinson‟s disease? Yes No Date of diagnosis: ______________________
(If no, please skip to the signature section.)

2. Motor manifestations due to Parkinson’s or its treatment: (check all that apply)

NOTE: VA may request additional medical information, including additional examinations if
necessary to complete VA‟s review of the Veteran‟s application.
FOR INTERNAL VA USE ONLY

****************************
B-cell Leukemia VAE Template

Hairy Cell and Other B-Cell Leukemias
Disability Benefits Questionnaire
Name of patient/Veteran: _____________________________________SSN: ____________________
The patient/Veteran has applied to the U. S. Department of Veterans Affairs for disability
benefits. Please complete this Questionnaire, which we need for our review of the
application.

1. Diagnosis: Does the Veteran now have or has he/she ever been diagnosed with hairy cell
leukemia or any other B-cell leukemia? Yes No
(If no, please skip to the signature section.)
Diagnosis (type of leukemia): _____________________________ Date of diagnosis: ______________

2. Status of disease: Active
Remission

3. Treatment: The Veteran is currently undergoing treatment for this leukemia with surgical,
radiation, immunotherapy, antineoplastic chemotherapy and/or other therapeutic
procedures.
The Veteran has completed treatment for this leukemia.
Date of discontinuance of treatment: _________________________________

4. Residual complications:
If six months or more have passed since discontinuance of leukemia treatment, does the
Veteran currently have any residual complications? Yes No
(If yes, please complete area below)
Residual complications requiring transfusion of platelets or red cells:
At least once every 6 weeks
At least once every 3 months
At least once per year but less than once every 3 months
Residual complications causing infections recurring:
At least once every 6 weeks
At least once every 3 months
At least once per year but less than once every 3 months
Residual complications related to anemia:
Bone marrow transplant due to aplastic anemia
Asymptomatic anemia
Symptomatic anemia (check signs and symptoms that apply)
weakness easy fatigability headaches
lightheadedness shortness of breath dyspnea on mild
exertion
cardiomegaly tachycardia syncope
high output congestive heart failure dyspnea at rest

The Secretary of the Department of Veterans Affairs (VA) recently established that ischemic heart disease, Parkinson‟s disease, and hairy cell and other chronic B-cell leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions. Our records indicate that you previously filed a claim for [insert name of new presumptive condition].

We have conducted a special review of your claims file mandated by the United States District Court‟s orders in Nehmer v. U.S. Department of Veterans Affairs.

This letter tells you about your award amount and payment start date and what we decided. It includes a copy of our rating decision that gives the evidence used and reasons for our decision. We have also included information about additional benefits, what to do if you disagree with our decision, and who to contact if you have questions or need assistance.

Your Estimated Retroactive Amount

The estimated amount of retroactive benefits is $[amount]. These retroactive benefits are a result of the United States District Court‟s order in Nehmer v. U.S. Department of Veterans Affairs. Please see Your Award Amount and Payment Start Date.

What We Decided
We granted service connection for [insert name of new presumptive here] for the purposes of entitlement to retroactive benefits, effective [date].
[Use standard PCGL paragraphs, if applicable]

Do You Have Dependents?
[Use standard PCGL paragraphs – include VA Form 21-686c and 21-674 for students in attachments]

The Secretary of the Department of Veterans Affairs (VA) recently established that ischemic heart disease, Parkinson‟s disease, and hairy cell and other chronic B-cell leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions. Our records indicate that you previously filed a claim for [insert name of new presumptive condition].

We have conducted a special review of your claims file mandated by the United States District Court‟s orders in Nehmer v. U.S. Department of Veterans Affairs.

This letter tells you what we decided. It includes a copy of our rating decision that gives the evidence used and reasons for our decision. We have also included information about what to do if you disagree with our decision, and who to contact if you have questions or need assistance.

What We Decided
[Use standard PCGL paragraphs]

What You Should Do If You Disagree With Our Decision
[Use standard PCGL paragraphs]

In Reply Refer To:
XXXXXXXX
CSS XXX XX XXXX
XXXXX, Xxxx Xxxx

84
If You Have Questions or Need Assistance
[Use standard PCGL paragraphs]

[POA - Use standard PCGL paragraphs]

Sincerely yours,

XXXXX
XXXXX
[Title]

Enclosure(s): Rating Decision
[Appropriate attachments]

****************************
Example Letter for DIC Grant

XXXX XXXX XXXXX
XXXX XXXXXXX XX
XXXXXX, XX XXXXX

Dear XXXXXXX:

The Secretary of the Department of Veterans Affairs (VA) recently established that ischemic heart disease, Parkinson‟s disease, and hairy cell and other chronic B-cell leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions. Our records indicate that [Name of Veteran] previously filed a claim for [insert name of new presumptive condition].

We have conducted a special review of your [DIC claimant’s relationship]‟s claims file mandated by the United States District Court‟s orders in Nehmer v. U.S. Department of Veterans Affairs.

This letter tells you about your award amount and payment start date and what we decided. It includes a copy of our rating decision that gives the evidence used and reasons for our decision. We have also included information about additional benefits, what to do if you disagree with our decision, and who to contact if you have questions or need assistance.

Your Estimated Retroactive Amount
The estimated amount of retroactive benefits based on [Veteran’s name]‟s claim for service connected compensation is $[amount]. The estimated amount of DIC retroactive benefits is $[amount]. [Make necessary adjustments to the paragraph to address the benefit payment].

These retroactive benefits are a result of the United States District Court‟s order in Nehmer v. Nehmer v. U.S. Department of Veterans Affairs. Please see Your Award Amount and Payment Start Date.

What We Decided
We granted service connection for [insert name of new presumptive here] for the purposes of entitlement to retroactive benefits, effective [date] until [date of death].

[Use all other necessary standard PCGL paragraphs]

How Do You Start Direct Deposit?
[Use standard PCGL paragraphs]

What Additional Information or Evidence Do We Still Need From You?
[Use standard PCGL paragraphs]

When and Where to Send the Information or Evidence
[Use standard PCGL paragraphs]

Are You Entitled to Additional Benefits?
[Use standard PCGL paragraphs]

What You Should Do If You Disagree With Our Decision
[Use standard PCGL paragraphs]

If You Have Questions or Need Assistance
[Use standard PCGL paragraphs]

[POA - Use standard PCGL paragraphs]

Sincerely yours,

XXXXX
XXXXX
[Title]

Enclosure(s): Rating Decision
[All Necessary Enclosures]

*****************************
Example Letter for DIC Denial

XXXX XXXX XXXXX
XXXX XXXXXXX XX
XXXXXX, XX XXXXX

Dear XXXXXXX:

The Secretary of the Department of Veterans Affairs (VA) recently established that ischemic heart disease, Parkinson‟s disease, and hairy cell and other chronic B-cell leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions. [If the Veteran filed a claim insert:] Our records indicate that [Name of Veteran] previously filed a claim for [insert name of new presumptive condition].

Our records indicate that you applied for dependency and indemnity compensation (DIC) benefits on [date].

We have conducted a special review of your [DIC claimant’s relationship]‟s claims file mandated by the United States District Court‟s orders in Nehmer v. U.S. Department of Veterans Affairs.

Every effort was made in considering your claim. This notification tells you what we decided, how we made our decision and what evidence we used to make our decision. We have also included information on what to do if you disagree with our decision and who to contact if you have questions or need assistance.

What We Decided
[Use standard PCGL paragraphs]

What You Should Do If You Disagree With Our Decision
[Use standard PCGL paragraphs]

In Reply Refer To:
XXXXXXXX
XSS XXX XX XXXX
XXXXX, Xxxx Xxxx

If You Have Questions or Need Assistance
[Use standard PCGL paragraphs]

[POA - Use standard PCGL paragraphs]

Sincerely yours,

XXXXX
XXXXX
[Title]

Enclosure(s): Rating Decision
VA Form 4107

****************************
Example Letter for Estate Grant

XXXX XXXX XXXXX
XXXX XXXXXXX XX
XXXXXX, XX XXXXX

Dear XXXXXXX:

The Secretary of the Department of Veteran Affairs (VA) has recently established that ischemic heart disease, Parkinson‟s disease, and hairy cell and other chronic B-cell leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions. Our records indicate that [Name of Veteran] previously filed a claim for [insert name of new presumptive condition] during his lifetime.

We have conducted a special review of the Veteran‟s claim file as mandated by the United States District Court‟s orders in Nehmer v. U.S. Department of Veterans Affairs. We have determined that the Veteran‟s Estate is entitled to retroactive compensation based on being a recognized class member as outlined in the above court order.

This letter tells you about the award amount and payment start date and what we decided. It includes a copy of our rating decision that gives the evidence used and reasons for our decision. We have also included information of what to do if you disagree with our decision, and who to contact if you have questions or need assistance.

Your Estimated Retroactive Amount

The estimated amount of retroactive benefits is $[amount]. This estimated payment was calculated using the new monthly entitlement amount minus any prior payments that were made along with any prior withholdings (if applicable) from the effective date(s) shown in the table below. These retroactive benefits are a result of the United States District Court‟s order in Nehmer v. U.S. Department of Veterans Affairs. Please see the Award Amount and Payment Start Date.

The Secretary of the Department of Veteran Affairs has recently established that ischemic heart disease, Parkinson‟s disease, and hairy cell and other chronic B- cell leukemias warrant presumptive service connection based on the association between exposure to herbicides used in the Republic of Vietnam and the subsequent development of these conditions. Our records indicate [Name of Veteran] previously filed a claim for [insert name of new presumptive condition] during his lifetime.

We have conducted a special review of the Veteran‟s claim file as mandated by the United States District Court‟s orders in Nehmer v. U.S. Department of Veterans Affairs. We have determined that you are entitled to retroactive compensation based on being a recognized class member as outlined in the above court order.

This letter tells you about your award amount and payment start date and what we decided. It includes a copy of our rating decision that gives the evidence used and reasons for our decision. We have also included information of what to do if you disagree with our decision, and who to contact if you have questions or need assistance.

Your Estimated Retroactive Amount

The estimated amount of your retroactive benefits is $[amount]. This estimated payment was calculated using the new monthly entitlement amount minus any prior payments that were made along with any prior withholdings (if applicable) from the effective date(s) shown in the table below. These retroactive benefits are a result of the United States District Court‟s order in Nehmer v. U.S. Department of Veterans Affairs. Please see Your Award Amount and Payment Start Date.

We're paying you as a recognized class member of the above named Veteran.

You Can Expect Payment
[Use standard PCGL paragraphs]

What You Should Do If You Disagree With Our Decision
[Use standard PCGL paragraphs]

If You Have Questions or Need Assistance
[Use standard PCGL paragraphs]

[POA - Use standard PCGL paragraphs]

Sincerely yours,

XXXXX
XXXXX
[Title]

Enclosure(s): Rating Decision
[Enclosures vary]
VA Form 4107

***********************

Appendix 11 – The Cardiovascular System in 38 C.F.R § 4.100 (Prior to
January 12, 1998)

Sec. 4.100 Necessity for complete diagnosis.

The common types of disease of the heart are those of rheumatic, syphilitic, arteriosclerotic, hypertensive, or hyperthyroid etiology. Determinations of relationship to service and evaluation, in the case of disability due to disease of the heart, require accurate identification of the disease, as an active or residual condition, with the complete required classification of etiology, structural lesions, manifestations, and capacity for work. Many common diagnoses following the first World War do not represent disease entities. ``Chronic myocarditis,'' for example, except as a continuing inflammation following an identified acute myocarditis due to rheumatic fever or other infectious agent, is not a satisfactory diagnosis; there should be further identification of the etiological agent and structural lesions, prior to rating action. The very common diagnosis ``mitral insufficiency'' is likewise unsatisfactory as reflecting organic valvular disease in the absence of associated mitral stenosis, definite cardiac enlargement without other causes, or history of rheumatic manifestations. An acceptable diagnosis
cannot be based upon the presence of systolic murmurs alone. Tachycardia and bradycardia, the various arrythmias, and cardiac hypertrophy or dilatation, do not represent generally acceptable diagnoses, and elevation or depression of the systolic or diastolic pressure is usually a manifestation of disease, rather than a clinical entity.

Sec. 4.101 Rheumatic heart disease.

Rheumatic fever is an acute infectious disease, affecting the structures about the joints (though without permanent bone damage) and, frequently, the endocardium. Children are as a rule affected, usually before the age of 20 years. Seldom is the initial attack after 25 years. The disease tends to recur, and serious heart trouble may follow the first or a subsequent attack. With acute rheumatic fever in service, perhaps without manifest damage to the heart, a subsequent recurrence of the infection, should be accepted as service connected. With even a few days service, service connection may be given for an acute rheumatic fever and any cardiac residuals. On the other hand, a mitral insufficiency without a history of rheumatic fever, chorea, or tonsillitis, or definite complication in service, must be considered as functional. Aortic insufficiency with a history of rheumatic fever and manifestation within approximately 15 years from the date of syphilitic infection, if any, should generally be considered rheumatic and always so when there is associated mitral or aortic stenosis. With a history of rheumatic fever in service, an aortic insufficiency manifest some years later without other cause shown may be service connected. The subsequent progress of rheumatic heart disease, and the effect of superimposed arteriosclerotic or hypertensive changes cannot usually be satisfactorily disassociated or separated so as to permit differential service connection. It is for this reason, in part, that great insistence is placed upon ascertainment of the service-connected disease as a true pathological entity. A subsequent change of diagnosis from one of an organic condition to one reflecting the effect of psychic or nervous factors casts doubt on the original diagnosis, but unless the correction is promptly made continuance of the service connection and of the evaluation under the new diagnosis is required. Such a change does not reflect an improvement of the physical condition.

Sec. 4.102 Varicose veins and phlebitis.

With severe varicose veins, tests to determine impairment of deep return circulation are essential, as the superficial varicosities may be caused by the impairment of deep return circulation, or there may be phlebitis as a complication of varicose ulcers. With phlebitis, or impairment of deep return circulation, the appropriate higher rating should be applied.

Sec. 4.103 [Reserved]

Sec. 4.104 Schedule of ratings--cardiovascular system.

Diseases of the Heart Rating
7000 Rheumatic heart disease:
As active disease and, with ascertainable cardiac
manifestation, for a period of 6 months..................………………………..100
Inactive:
Definite enlargement of the heart confirmed by roentgenogram
and clinically; dyspnea on slight exertion; rales,
pretibial pitting at end of day or other definite signs of
beginning congestive failure; more than sedentary
employment is precluded..................................…………………………..100
The heart definitely enlarged; severe dyspnea on exertion,
elevation of systolic blood pressure, or such arrhythmias
as paroxysmal auricular fibrillation or flutter or
paroxysmal tachycardia; more than light manual labor is
precluded................................................…………………………………...60
From the termination of an established service episode of
rheumatic fever, or its subsequent recurrence, with cardiac
manifestations, during the episode or recurrence, for 3
years, or diastolic murmur with characteristic EKG
manifestations or definitely enlarged heart..............………………………30
With identifiable valvular lesion, slight, if any dyspnea,
the heart not enlarged; following established active
rheumatic heart disease.................................……………………………..10
7001 Endocarditis, bacterial, subacute.
7002 Pericarditis, bacterial or rheumatic, acute.
Rate as rheumatic heart disease.
7003 Adhesions, pericardial:
Extensive, obliterating the sac, with congestive heart failure 100
Rate lesser conditions as rheumatic heart disease, inactive.
7004 Syphilitic heart disease:
Rate as rheumatic heart disease, inactive.
7005 Arteriosclerotic heart disease:
During and for 6 months following acute illness from coronary
occlusion or thrombosis, with circulatory shock, etc......………………….100
After 6 months, with chronic residual findings of congestive
heart failure or angina on moderate exertion or more than
sedentary employment precluded............................……………………...100
Following typical history of acute coronary occlusion or
thrombosis as above, or with history of substantiated
repeated anginal attacks, more than light manual labor not
feasible...................................................…………………………………….60
Following typical coronary occlusion or thrombosis, or with
history of substantiated anginal attack, ordinary manual
labor feasible.............................................………………………………….30
7006 Myocardium, infarction of, due to thrombosis or embolism.
Rate as arteriosclerotic heart disease.
7007 Hypertensive heart disease:
With definite signs of congestive failure, more than sedentary
employment precluded......................................…………………………..100
With marked enlargement of the heart, confirmed by
roentgenogram, or the apex beat beyond midclavicular line,
sustained diastolic hypertension, diastolic 120 or more,
which may later have been reduced, dyspnea on exertion, more
than light manual labor is precluded.......................………………………..60
With definite enlargement of the heart, sustained diastolic
hypertension of 100 or more, moderate dyspnea on exertion..…………..30
7008 Hyperthyroid heart disease:
With signs of congestive failure...........................………………………….100
With permanent or paroxysmal auricular fibrillation.........………………….60
Note: The ratings under Code 7008 are not to be combined with
ratings for hyperthyroidism. Rate lesser conditions as
hyperthyroidism.
Cardiac neurosis.
Refer to psychiatric schedule.
Note: The following Codes 7010 through 7015 reflecting
arrhythmias and conduction abnormalities are occasionally
encountered. Standing alone they represent incomplete
diagnoses. Ratings are not to be combined with those for
other heart or psychiatric conditions.
7010 Auricular flutter, paroxysmal.
Rate as paroxysmal tachycardia.
7011 Auricular fibrillation, paroxysmal.
Rate as paroxysmal tachycardia.
7012 Auricular fibrillation, permanent.......................………………………...10
7013 Tachycardia, paroxysmal:
Severe, frequent attacks....................................…………………………….30
Infrequent attacks.........................................…………………………………10
7014 Sinus tachycardia:
Persistently 100 or more in recumbent position.............……………………10
7015 Auriculoventricular block:
Complete; with attacks of syncope necessitating the insertion
of a permanent internal pacemaker, and for 1 year, after
which period the rating will be on residuals as below......…………………100
Complete: with Stokes-Adams attacks several times a year
despite the use of medication or management of the heart
block by pacemaker.........................................………………………………60
Complete; without syncope or minimum rating when pacemaker has
been inserted..............................................………………………………….30
Incomplete; without syncope but occasionally symptomatic...……………..10
Incomplete; asymptomatic, without syncope or need for
medicinal control after more than 1 year...................………………………..0
Note 1: Atrioventricular block, partial or complete, may be
present associated with and related to the supraventricular
tachycardias or pathological bradycardia. Cases with Mobitz
Type II block may be encountered, as well as Wenckebach's
phenomenon, Mobitz Type I block, and varying degrees of A-V
block associated with tachyarrhythmias or other severe
disturbances in rate or rhythm. Such unusual cases should be
submitted to the Director, Compensation and Pension Service.
On the other hand, simple delayed P-R conduction time, in the
absence of other evidence of cardiac disease, is not a
disability.
Note 2: The 100 percent rating for 1 year following
implantation of permanent pacemaker will commence after
initial grant of the 1 month total rating assigned under Sec.
4.30 following hospital discharge.
7016 Heart valve replacement (prosthesis):
For 1 year following implantation of prosthetic valve......…………100
Thereafter; rate as rheumatic heart disease; minimum rating.……30
Note: The 100 percent rating for 1 year following implantation
of prosthetic valve will commence after initial grant of the
1 month total rating assigned under Sec. 4.30 following
hospital discharge.
7017 Coronary artery bypass:
For 1 year following bypass surgery........................………………100
Thereafter, rate as arteriosclerotic heart disease.
Minimum rating............................................……………………….30
Note: Authentic myocardial insufficiency with arteriosclerosis
may be substituted for occlusion.
Note: The 100 pct rating for 1 year following bypass surgery
will commence after the initial grant of the 1-month total
rating assigned under Sec. 4.30 following hospital
discharge.
------------------------------------------------------------------------

Diseases of the Arteries and Veins
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
7100 Arteriosclerosis, general:
With slight weakening of bodily vigor.......................………………..20
Without symptoms or renal, cardiac, or cerebral complications. 0
Note: Rate the arteriosclerotic complications, such as renal,
cardiac, or cerebral, under the appropriate schedule.
7101 Hypertensive vascular disease (essential arterial
hypertension):
Diastolic pressure predominantly 130 or more and severe
symptoms..................................................………………………….60
Diastolic pressure predominantly 120 or more and moderately
severe symptoms...........................................………………………40
Diastolic pressure predominantly 110 or more with definite
symptoms...................................................…………………………20
Diastolic pressure predominantly 100 or more...............…………..10
Note 1: For the 40 percent and 60 percent ratings under code
7101, there should be carefull attention to diagnosis and
repeated blood pressure readings.
Note 2: When continuous medication is shown necessary for
control of hypertension with a history of diastolic blood
pressure predominantly 100 or more, a minimum rating of 10
percent will be assigned.
7110 Aneurysm, aortic, fusiform, sacular, dissection and/or
with stenosis:
After establishment of diagnosis with markedly disabling
symptoms; and for 1 year after surgical correction (with any
type graft)...............................................…………………………..100
If exertion and exercise is precluded......................………………...60
Thereafter, rate residual of graft insertion according to
findings and symptoms under most appropriate analogy.
Minimum rating.............................................………………………..20
Note: The 100 percent rating for 1 year following surgical
correction will commence after initial grant of the 1-month
total rating under Sec. 4.30 assigned following hospital
discharge.
7111 Artery, any large artery, aneurysm of:
In lower extremities, symptomatic...........................………………..60
In upper extremities, symptomatic..........................……………..…40
Note: Rate post-operative residuals with graft insertion under
most appropriate analogy, e.g., 7116, etc., minimum rating 20
percent.
7112 Artery, small, aneurysmal dilatation of................……………..10
7113 Arteriovenous aneurysm, traumatic:
With cardiac involvement, minimum rating....................……………60
Without cardiac involvement with marked vascular symptoms.
Lower extremity.............................................………………………..50
Upper extremity.............................................………………………..40
With definite vascular symptoms.
Lower extremity.............................................………………………..30
Upper extremity.............................................………………………..20
7114 Arteriosclerosis obliterans.
7115 Thromboangiitis obliterans (Buerger's disease).
7116 Claudication, intermittent:
Severe form with marked circulatory changes such as to produce
total incapacity or to require house or bed confinement..………..100
Persistent coldness of extremity with claudication on minimal
walking....................................................……………………………60
Well-established cases, with intermittent claudication or
recurrent episodes of superficial phlebitis................……………….40
Minimal circulatory impairment, with paresthesias, temperature
changes or occasional claudication.........................……………….20
Note: The 100 percent rating will not be applied under a
diagnosis of intermittent claudication.
7117 Raynaud's disease:
Severe form with marked circulatory changes such as to produce
total incapacity or to require house or bed confinement...……….100
Multiple painful, ulcerated areas...........................…………………..60
Frequent vasomotor disturbances characterized by blanching,
rubor and cyanosis.........................................………………………40
Occasional attacks of blanching or flushing............………………...20

Note: The schedular evaluations in excess of 20 percent under
Diagnostic Codes 7114, 7115, 7116, and 7117 are for
application to unilateral involvements. With bilateral
involvements, separately meeting the requirements for
evaluation in excess of 20 percent, 10 percent will be added
to the evaluation for the more severely affected extremity
only, except where the disease has resulted in an amputation.
The resultant amputation rating will be combined with the
schedular rating for the other extremity, including the
bilateral factor, if applicable. The 20 percent evaluations
are for application to unilateral or bilateral involvement of
both upper and lower extremities.
7118 Angioneurotic edema:
Severe; frequent attacks with severe manifestations and
prolonged duration.........................................………………………40
Moderate; frequent attacks of moderate extent and duration.…….20
Mild; infrequent attacks of slight extent and duration....……………10
7119 Erythromelalgia:
Severe.....................................................……………………………40
Moderate...................................................…………………………..20
Mild........................................................……………………………..10
7120 Varicose veins.
Pronounced; unilateral or bilateral, the findings of the
severe condition with secondary involvement of the deep
circulation, as demonstrated by Trendelenburg's and Perthe's
tests, with ulceration and pigmentation:
Bilateral.................................................……………………………60
Unilateral...............................................……………………………50
Severe; involving superficial veins above and below the knee,
with involvement of the long saphenous, ranging over 2 cm. in
diameter, marked distortion and sacculation, with edema and
episodes of ulceration; no involvement of the deep
circulation:
Bilateral................................................……………………………..50
Unilateral................................................……………………………40
Moderately severe; involving superficial veins above and below
the knee, with varicosities of the long saphenous, ranging in
size from 1 to 2 cm. in diameter, with symptoms of pain or
cramping on exertion; no involvement of the deep circulation:
Bilateral.................................................…………………………….30
Unilateral................................................……………………………20
Moderate; varicosities of superficial veins below the knees,
with symptoms of pain or cramping on exertion:
Bilateral or unilateral..................................…………………………10
Mild; or with no symptoms.................................…………………….0
Note: Severe varicosities below the knee, with ulceration,
scarring, or discoloration and painful symptoms will be rated
as moderately severe.
7121 Phlebitis or thrombophlebitis, unilateral, with
obliteration of deep return circulation, including traumatic
conditions:
Massive board-like swelling, with severe and constant pain at
rest.......................................................…………………………….100
Persistent swelling, subsiding only very slightly and
incompletely with recumbency elevation with pigmentation
cyanosis, eczema or ulceration.............................…………………60
Persistent swelling of leg or thigh, increased on standing or
walking 1 or 2 hours, readily relieved by recumbency;
moderate discoloration, pigmentation and cyanosis or
persistent swelling of arm or forearm, increased in the
dependent position; moderate discoloration, pigmentation or
cyanosis...................................................…………………………..30
Persistent moderate swelling of leg not markedly increased on
standing or walking or persistent swelling of arm or forearm
not increased in the dependent position...................………………10
Note: When phlebitis is present in both lower extremities or
both upper extremities, apply bilateral factor.
7122 Frozen feet, residuals of (immersion foot).
With loss of toes, or parts, and persistent severe symptoms:
Bilateral.................................................…………………………….50
Unilateral................................................…………………………....30
With persistent moderate swelling, tenderness, redness, etc:
Bilateral................................................……………………………..30
Unilateral................................................…………………………...20
With mild symptoms, chilblains:
Bilateral...............................................……………………………...10
Unilateral...............................................…………………………….10
Note: With extensive losses higher ratings may be found
warranted by reference to amputation ratings for toes and
combination of toes; in the most severe cases, ratings for
amputation or loss of use of one or both feet should be
considered. There is no requirement of loss of toes or parts
for the persistent moderate or mild under this diagnostic
code.
7123 Soft-tissue sarcoma (of vascular origin)..............…………..100
Note: The 100 percent rating will be continued for 6 months
following the cessation of surgical, X-ray, antineoplastic
chemotherapy or other therapeutic procedure. At this point, if
there has been no local recurrence or metastases, the rating
will be made on residuals.
[29 FR 6718, May 22, 1964, as amended at 40 FR 42539, Sept. 15, 1975; 41
FR 11300, Mar. 18, 1976; 43 FR 45361, Oct. 2, 1978; 56 FR 51653, Oct.
15, 1991]

Appendix 12 – MAP-D Notification/Development Paragraphs for Nehmer

Introductory Paragraph – Development Letter Issued Prior To Final
Regulation

We are conducting a special review of [Veteran‟s name/your] claims folder in accordance with Nehmer v. U.S. Department of Veterans Affairs (VA), which requires the payment of retroactive benefits to certain Nehmer class members. Your case was identified as a potential Nehmer class-member case based on the addition of Ischemic Heart Disease, Parkinson‟s Disease, and B-cell/Hairy cell leukemias to the list of diseases presumptively associated with exposure to certain herbicide agents used in Vietnam. Entitlement to potential retroactive benefits applies to all cases wherein VA received a claim, or a claim for benefits was pending, or wherein VA denied benefits, on or after September 25, 1985, and before the date VA publishes the final regulation adding the new disabilities to the list of diseases presumptively associated with herbicide exposure in Vietnam.

Your case qualifies for this special review based on a prior VA benefits claim for [insert the newly added presumptive disease]. However, this disease has not yet been added to VA regulations governing disabilities presumptively associated with herbicide exposure. In order to add this disease, we must follow a series of legal requirements, including publishing a notice in the Federal Register. We have begun this process, but in the meantime we are requesting evidence necessary for this review so that we may expedite your decision once the regulation becomes final.

IMPORTANT NOTE TO VSRs: If no additional development is required, edit
the last sentence in the second paragraph, “We have begun this process
…” before sending the notification letter to the class member.

Introductory Paragraph – Development Letter Issued After Final Regulation

We are conducting a special review of [Veteran‟s name/your] claims folder in accordance with Nehmer v. U.S. Department of Veterans Affairs (VA), which requires the payment of retroactive benefits to certain Nehmer class members. Your case was identified as a potential Nehmer class-member case based on the addition of Ischemic Heart Disease, Parkinson‟s Disease, and B-cell/Hairy Cell Leukemia to the list of diseases presumptively associated with exposure to certain herbicide agents used in Vietnam. [Entitlement to potential retroactive benefits applies to all cases wherein VA received a claim, or a claim for benefits was pending, or wherein VA denied benefits, on or after September 25, 1985, and before the date VA publishes the final regulation adding the new disabilities to the list of diseases presumptively associated with herbicide exposure in Vietnam.] Your case qualifies for this special review based on a prior VA benefits claim for [insert the newly added presumptive disease].

VAE Paragraph

You may be able to help us expedite your case if you can have your VA or private physician complete the enclosed VA Examination Worksheet. Submitting this worksheet may eliminate the need for VA to schedule a Compensation and Pension examination to obtain current rating criteria on your case. This may help us make a decision faster. Have the physician complete all portions of the worksheet and ensure that he or she signs and dates the worksheet. In order to fully assist VA in expediting your case, please submit the examination worksheet within 30 days. If you cannot provide this information, your physician refuses to assist, or we otherwise have not received it within 30 days, we may proceed with scheduling an examination for you.

Soliciting Other Evidence Paragraph

If you have any additional information that you may consider helpful in the review of your claim, please provide us a copy of such information as soon as possible. Examples of additional information include, but are not limited to marriage certificates, birth certificates, Social Security numbers, and medical reports. Historical medical reports are especially important if your claim(s) was denied long ago and you have subsequent medical treatment records from the time the claim was filed to the present, including any period in between.

2b. What is the date of receipt of each of the prior claim(s) from item 2? [Auto list of claims from item 2] [User will enter date of receipt of each claim]

3. What is the type of medical evidence used to verify the disability for: [Auto list of diseases from 2a] [User selects-multiple selections apply for type medical evidence (VHA; Private Treatment or Other (SSA, etc) used for each disability identified]

Example:
NOTE TO VBN USERS: THIS IS IN A BOX FORM BUT I’M UNABLE TO MAKE ONE.

4. What is the rating date that disposed of the issue(s) from items 2/2b? [User will enter date of rating that disposed of the claim(s) identified in item 2-Auto list of claims will be generated] [If N/A is checked continue to item 5]

5. What was the disposition of the claim(s) from item 4? [Auto list of the claims identified in item 2 and drop-down choices are grant (enter effective date benefits granted), denial or outstanding] [If grant is checked, skip item 7 and go to item 8]

6. Is there a subsequent grant of the previous denial or deferral of benefits, and if so, insert the effective date for benefits that were previously granted based on the oldest prior claim from item 2. [User will enter the effective date benefits were previously granted]

7. Does the Veteran meet all three eligibility requirements? [User will select Y/N]
[If “YES” go to item 8]
[If “NO”, identify the eligibility requirement(s) not met and skip to item 32 check boxes-multiple selections permitted for deficiencies; a selection is required]


No in-country VN service [If this is chosen, proceed to 7a]

No prior claim filed or denied between 9/25/85 and [automatic insert date- date pending of final regulation-unknown at this time]

No diagnosis of claimed disability(ies)

7a. Is development required? [User will select Y/N] [If YES proceed to 8; If NO
skip to 32]

9. Was a SC claim filed for any other based upon exposure to herbicides used in Vietnam disability? [User will select Y/N]
[If “YES”, User must select disability(ies) from the drop box and proceed to items 10-12]
[If “NO” is checked, Auto skip of this area and proceed to the area entitled “Death Claims”]

Death Claim [If the Veteran is living-skip this entire area go to items under
“Review Summary”]

13. Was there a claim for death benefits-to include burial filed or denied between 9/25/85 and [Auto date based on disability claimed]? [Y/N-User entry]
[If Yes, proceed to Q14]
[If No, Allow only Q15 and skip to Q19]

14. What is the date of receipt of death claims? [User will enter date-required entry]

15. What is the date of death? [User will enter date-required entry]

16. What is the Veteran's primary, secondary or contributory cause of death caused by [Auto list of disabilities identified in items 2a and 9-Allow for multiple selections of disabilities and for each disability, allow for the following drop-down choices: primary, secondary, contributory, N/A. Allow for one choice only].


Grant with medical development [If a grant with medical development is indicated proceed to 21]

Full grant with no additional medical development [If a full grant is indicated skip to item 31]

Denial [If Denial is indicated, skip to item 32]

Memorandum for the record [If a memo is indicated skip to item 32 41]

Confirmed and continued (C&C) [If a C&C id indicated skip to item 32]

20. Is development action(s) required before a rating can be prepared? [Y/N-
User entry]
[If „YES‟, proceed to Rating Development Action(s) Required and do not allow an entry in items identified under Ready-to-Rate section (Q32-34)]
[If “NO”, proceed to Rating Development Action(s) Required and allow for entry in the Ready-to-Rate section (Q32-34)]

28a. Enter the date the requested evidence was received [User will insert date- required entry] and proceed to “RVSR Decision” section.

29 Was the (request for evidence) mail returned undeliverable? [Y/N-User entry]
[If “YES” an entry is required in item 29a]
[If “NO”, go to Q30]

29a. If the (request for evidence) mail was returned undeliverable, is the
requested evidence required in order to rate the claim? [Y/N-User entry]
[If “NO” proceed to item 32]
[If “YES” is selected go to “Decision Notice Area”]

42b. Did SME review the Nehmer claim for quality? [Y/N-User entry]
[If Y, User must input date of review. Do not allow date entered in 42b to be earlier than date shown in Q42. Continue to Q42c]
[If N, Skip to Q43]

The case of Nehmer v. United States Veterans' Administration originated in 1986 as a class-action lawsuit against VA by Vietnam veterans and their survivors who alleged that VA had improperly denied their claims for service connection for disability or death allegedly caused by exposure to the herbicide Agent Orange in service.

In a May 3, 1989, decision, the United States District Court for the Northern District of California ruled in the Nehmer case that a VA regulation, issued in 1985, which implemented legislation directing the establishment of standards and criteria for adjudication of claims by Vietnam veterans allegedly suffering from herbicide-related disabilities, was invalid because the "cause and effect" standard used in the regulation was inconsistent with the intent of Congress. The court concluded that Congress intended VA to apply a more lenient standard requiring only a "significant statistical association" between herbicide exposure and the occurrence of a disease in exposed persons. The court invalidated VA's regulation and voided all benefit denials under that regulation.

In May 1991, the Nehmer parties entered into a "Final Stipulation and Order" (Final Stipulation) outlining the actions to be taken in response to the court's decision. Among other things, the Final Stipulation provided, in general: (1) that VA would issue new regulations in accordance with the Agent Orange Act of 1991; (2) that, after issuing such regulations, VA would readjudicate those claims where a prior denial had been voided by the court's 1989 order and would initially adjudicate all similar claims filed subsequent to the court's order; and (3) that, if benefits were awarded upon such readjudication or adjudication, the effective date of the award would be the date the claim was filed.

In a February 11, 1999, decision, the district court explained and clarified the scope of its 1989 decision. The court stated that its 1989 decision had voided all VA decisions that were rendered while the invalid regulation was in effect and which denied service connection for a Vietnam veteran's disease that was later found to be associated with herbicide exposure under the regulations issued under the Agent Orange Act of 1991. The court explained that it was irrelevant whether the claimant or VA had referenced herbicide exposure or the invalid regulation in connection with the prior claim. Pursuant to that decision, the effective date of service connection granted under the 1994 regulations establishing presumptions of service connection for certain diseases may relate back to the date of an earlier claim for service connection of the same disease, regardless of whether the earlier claim was expressly based on herbicide exposure.

Last year. VA promulgated 38 C.F.R. § 3.816, which codified the procedures for adjudicating claims under the Final Stipulation. On January 21, 2004, class counsel asserted in a letter to the Department of Justice (DOJ) that footnote 1 in paragraph 5 of the Final Stipulation establishes a substantive rule that VA failed to address in section 3.816. Paragraph 5 states, in relevant part, as follows:

For any of the [presumptive diseases], as to any
denials of claims which were voided as a result of the
Court's May 3, 1969 Order, the effective date for
disability compensation or dependency and indemnity
compensation ... , if the claim is allowed upon
readjudication ... , will be the date the claim giving rise
to the voided decision was filed ..., assuming the
basis upon which compensation is granted after
readjudication is the same basis upon which the
original claim was filed,1 or the date the claimant
became disabled or death occurred, whichever is
later. In the event the basis upon which a claim for
compensation benefits is granted after readjudication
is different than the basis for the original claim giving
rise to the voided decision,2

the effective date ... will
be the date on which the claim asserting the basis
upon which the claim is granted was filed, or the date
the claimant became disabled or death occurred,
whichever is later.

(emphasis added). Footnote 1 provides: "The basis upon which the original claim was filed refers to the disease[s] or condition[s] which Chapter 46 of VA Manual M21-1, paragraph 46.02 required to be coded in the ratings decision contained in the claimant's claim file, which ratings decision was voided by the Court's May 3, 1989 Order." (emphasis added).

At the time that the parties entered the Final Stipulation, paragraph 46.02 of VA Adjudication Procedure Manual M21-1 (1965) provided:

a. Compensation Ratings. All disabilities claimed will
be given consideration as to service connection and
be coded as a disability rating on VA Form 21-6796.
Any additional disabilities noted will be coded, except:
(1) Acute transitory conditions that leave no residuals.
(2) Noncompensable residuals of venereal disease.
(3) Disabilities noted only on the induction
examination, or conditions recorded by history only.
(4) Disabilities found by authorization to have not
been incurred "in line of duty".

b. Pension Ratings. Code all claimed or noted
disabilities on VA Form 21-6796 and show the
percent of disablement for each unless the disabilities
have been held to be due to the claimant's own willful
misconduct by Administrative Decision.

(cross references omitted). The Final Stipulation defined "the basis upon which the original claim was filed" with reference to paragraph 46.02 of the manual, which established the requirement that additional noted disabilities be "coded," unless a listed exception applied. Among other things, the manual provision excepted from the coding requirement "conditions recorded by history only." Thus, noted disabilities that have been diagnosed were required to be coded in a rating decision even though the claimant may not have raised any issue concerning those disabilities in the claim being adjudicated. The provision is clear that the term "code" refers to rating codes, not diagnostic codes. Accordingly, a condition that the paragraph 46.02 language "required to be coded," is one that the provision required to be rated in a decision.

Class counsel asserts that the paragraph 46.02 language, which footnote 1 incorporated in the Final Stipulation, established "objective criteria ... for determining whether a rating decision denied compensation for a particular disease." Class counsel further contends that a claim falls within the effective- date provisions of paragraph 5 of the Final Stipulation "if paragraph 46.02 of M21-1 required the covered Agent Orange-related disease to be 'coded' in the rating decision on the claim." In our view, this is a reasonable interpretation of the Final Stipulation because it is consistent with the court's and the parties' intent to provide a remedy for the Nehmer class. In other words, in the context of this litigation, it is reasonable to assume that, in 1991, the court and the parties intended to provide a remedy for persons with diagnosed herbicide-related conditions who either received a rating decision denying an express claim for service connection for that condition; received a rating decision that addressed (coded as non-service-connected) an unclaimed herbicide-related condition; or received a rating decision that failed to address a noted condition (failed to code the condition). Each of these types of "decisions" could be viewed as being voided by the court's May 1989 order. However, section 3.816 currently covers only the first type of decision.

A second reasonable but less pro-veteran interpretation of the footnote is that it merely prescribes how to determine the correct effective date for adjudications conducted under paragraph 3 and 4 of the Final Stipulation. Paragraph 3 provides that as soon as VA issues a final rule service-connecting any disease under the Agent Orange Act of 1991, it "shall promptly thereafter readjudicate all claims for any such disease which were voided by the Court's Order of May 3, 1989." Paragraph 4 provides that VA shall rely upon its Special Issue Rating System (SIRS) or notice from an individual claimant to identify claimants who received qualifying denials. Identified claimants may then be awarded an earlier effective date using the paragraph 5 criteria. Class counsel essentially argues that paragraph 5, rather than paragraphs 3 and 4, identifies the claim denials that the district court voided in its May 1989 decision. That argument is arguably incorrect because it reads paragraph 5 out of context and ignores the paragraph 4 provision that requires VA to use SIRS to identify eligible claimants. SIRS does not contain information concerning unclaimed disabilities that paragraph 46.02 of Manual M21-1 required to be coded.

Class counsel intends to bring this matter to the district court's attention if we refuse to amend section 3.816. As stated above, the Final Stipulation is subject to two reasonable interpretations, only one of which could be viewed as expanding the remedy available to the Nehmer classmembers. Clearly, the district court has every reason to select the interpretation proposed by class counsel, as it is a reasonable, pro-veteran interpretation that is consistent with the purpose of the Final Stipulation. In addition, the court could conclude that application of the alternative interpretation would lead to an absurd result. For example, a veteran who, in 1986, flied a claim for service connection for respiratory cancer and received a rating decision denying that claim would be entitled to retroactive benefits under Nehmer. However, another veteran, who was also diagnosed with a respiratory cancer and who deliberately limited his 1986 claim to a back condition, knowing that VA could not service-connect his cancer in the absence of a presumption. would not be entitled to retroactive benefits under Nehmer.

The pro-veteran interpretation would require a minor amendment to section 3.816(c)(1), which governs effective dates for decisions voided by the district court's May 3, 1989, order. Footnote 1 does not apply where the decision on a claim was made after May 3, 1989.

Amendment of 3.816(c)(1) would affect very few claims. Less than one percent of all claims identified for further adjudication by the Nehmer plaintiffs' review of claims files in discovery involved unclaimed conditions that were required to be coded under paragraph 46.02 of Manual M21-1. Further, plaintiffs' file review has covered all herbicide-related presumptive conditions, except type 2 diabetes. which VA service. connected effective July 9, 2001 {the U.S. Court of Appeals for the Federal Circuit later changed the effective date of the regulation service- connecting type 2 diabetes to May 8, 2001, in Liesegang v. Secretary of Veterans Affairs, 312 F.3d 1368 (Fed. Cir. 2002)).

With respect to type 2 diabetes, amendment of section 3.816 might require readjudication of some claims. However, VA has already agreed to readjudicate all identifiable type 2 diabetes claims. As stated above, paragraph 4 of the Final Stipulation requires VA to use its SIRS database to identify claimants entitled to readjudication under Nehmer. Although SIRS no longer exists, VA searched its VITALS database for type 2 diabetes claimants that filed claims prior to 1999. That search identified 2,777 claimants with potential eligibility under Nehmer. VA issued a Nehmer readjudication notice (required by paragraph 4 of the Final Stipulation) to 1,756 of those claimants and, in Fast letter 02-33, instructed the regional offices to readjudicate their c\aims. VA has not provided a readjudication notice to the remaining claimants and has not initiated readjudication of their claims. On December 7, 2000, VA issued Fast Letter 00-91, instructing the regional offices to establish “685 diary" with a July 1, 2001, suspense date for any claim seeking service connection for type 2 diabetes based upon herbicide exposure in Vietnam. On June 14, 2001, VA issued Fast Letter 01-51, which instructed the regional offices to use July 9, 2001, as the effective date for benefits awarded for type 2 diabetes. Because VA believed that Nehmer might require readjudication of those claims, the regional offices were instructed to use the "685 diary" for tracking decisions. On October 19, 2001, VA issued Fast letter 01-94, which instructed the regional offices to begin applying Nehmer to type 2 diabetes claims. VA later entered into a stipulation in which it agreed to readjudicate all of the type 2 diabetes claims controlled under the “685 diary" (13,318 claims). Although VA readjudicated those claims, a decision was recently made to conduct a full second review.

As part of its compliance with the Federal Circuit's Liesegang decision, VA identified 9,340 claimants that filed claims for type 2 diabetes, had Vietnam service, and received a compensation award effective between May 7, 2001, and August 2, 2001.

The 9,340 "Liesegang claimants" are probably also listed among the 13,318 "685 diary claimants." Accordingly, except for the 1,756 claims that have already been readjudicated under Fast letter 02-33, we conclude that it would be prudent for VA's upcoming readjudication of 14,339 type 2 diabetes claims (13,318 controlled by the "685 diary" and the 1,021 claims identified from VITALS that remain unadjudicated) to apply the proposed amendment to all identifiable claims that are outside the scope of the district court's discovery orders.

VA's recent decision to conduct a second review of the 13,318 type 2 diabetes claims was prompted in part by quality concerns. Class counsel has demanded that VA produce its quality review data and has threatened to raise the issue before the district court. DOJ refused that request based upon VA's decision to conduct a second review of all 13,318 claims. Amending section 3.816 would provide another basis for conducting the second review and might tend to neutralize class counsel's argument that he is entitled to the quality review data.

Appendix 16 – VSR and SVSR Responsibilities

VSR Responsibilities:

- Inputting the award data into the appropriate awards system. Most awards should be processed in VETSNET.
- Assuring that all prior payments are put into BDN or VETSNET if already in receipt of benefits. RVSR backfills award. Manual adjustments may be required.
- Generating an award document.
- Preparing a notification letter.
- Annotating the award with the presumptive condition.
- Signing the award

SVSR Responsibilities:

- Reviewing the award and notification letter for accuracy.
- Co-signing the award.
- Assuring that a third level review is performed prior to award authorization, in cases involving retroactive payments greater than $25,000.
- Sending the file for review by the Nehmer Subject Matter Expert (SME) when selected for quality review.
- Submitting copies of the memorandum for the record and the Payment History Inquiry Screen upon request by OGC.
- Incorporating a copy of the database into the file

TRAINING CASE SCENARIOS

VSR Scenario 1

You receive a file for review. The DD Form 214 shows the Veteran served in the Navy from June 1, 1962, to August 30, 1973. The file also includes a DPRIS request response showing the Veteran served in-country in the Republic of Vietnam from August 10, 1970, to November 30, 1972.

The Veteran filed an original claim for service connection for IHD on April 3, 1998. Medical evidence was submitted showing a diagnosis of IHD. The Veteran was denied service connection and notified of the decision on August 17, 1998.

On December 23, 1998, the Veteran then filed a claim for Pension benefits. The Veteran listed IHD under conditions that contributed to his unemployability. Medical evidence dated December 20, 1998, was submitted with a Pension claim showing chronic congestive heart failure. Pension was granted effective December 23, 1998, with diagnostic code 7005.

The Veteran passed away on January 27, 1999, with the secondary cause of death listed as Ischemic heart disease (IHD).

September 20, 2007, the surviving spouse of the Veteran filed a claim for DIC and was denied and notified on February 19, 2008, due to lack of evidence showing that IHD was caused by service.

VSR has confirmed that the surviving spouse is living and has not remarried since the death of the Veteran. Evidence of record shows they were married from 1990 until the date of death. No children are of record.

Questions

1) Is this a Nehmer case?

2) Are there any retroactive benefits payable?

3) What effective date(s) should be assigned for retroactive compensation, if applicable?

4) What is the effective date for DIC, if applicable?

5) Is any additional development necessary? If so, what development is required? If not, what is the next action?

VSR Scenario 2

A case arrives at your desk for review. The BIRLS VID screen shows that the Veteran is currently alive.

A review of the record shows that the Veteran served in-country in the Republic of Vietnam and has a combined rating of 30 percent without dependents. The Veteran‟s current rating code sheet shows that she is rated 10 percent for type II diabetes mellitus (Agent Orange) and 20 percent for a left knee condition. Both conditions were granted effective May 17, 2002, the date the Veteran claimed these conditions.

The Veteran filed a claim for hairy cell leukemia (HCL) on January 10, 1985. The Veteran‟s claim was denied and notified on September 12, 1985, because the condition was not incurred nor aggravated by service and the condition was not caused by herbicide exposure. Diagnostic code 7700 was used to prepare the rating. Evidence received on January 10, 1985, shows the Veteran was diagnosed with inactive HCL with original diagnosis on November 12, 1984.

Questions

1) Is this a Nehmer case?

2) Is the Veteran entitled to retroactive compensation?

3) What effective date(s) should be assigned for retroactive compensation, if applicable?

4) Is any additional development necessary? If so, what development is required? If not, what is the next action?

VSR Scenario 3

You receive a file for review. A DD Form 214 in the file shows the Veteran served in the Navy from February 2, 1960, to May 31, 1981, and that the Veteran received a Vietnam Service Medal. The dates of service were verified using a DPRIS request; however, in-country service was not verified.

The Veteran filed an original claim for service connection for PD on March 29, 2005. Medical evidence was submitted showing a diagnosis of PD. The Veteran was denied service connection on July 10, 2005, under diagnostic code 8002.

A review of the file shows that the Veteran passed away on October 8, 2006, with the contributory cause of death listed as Parkinson‟s disease (PD). The Veteran was not in receipt of benefits and did not have a claim pending at time of death.

A claim for burial benefits was submitted on October 15, 2006, from Jane Doe. The application indicated that she was not filing a claim for service-connected death. Jane also listed herself as the surviving spouse on the application. Evidence of record shows that Jane was the surviving spouse since 1979 and has not remarried since the date of death. No children are of record. VA did not send VA Form 21-534, Application for DIC, Death Pension & Accrued Benefits by Surviving Spouse or Child.

The claim for burial benefits was denied as the Veteran was not in receipt of compensation or pension benefits. The death certificate shows the address of the deceased to be the same as that of the surviving spouse.

Questions

1) Is this a Nehmer case?

2) Are there retroactive benefits?

3) What effective date(s) should be assigned for retroactive compensation, if applicable?

4) Is Jane Doe entitled to service connected burial benefits?

5) What is the effective date for DIC, if applicable?

6) Is any additional development necessary? If so, what development is required? If not, what is the next action?

VSR Scenario 4

A case arrives at your desk for review. The BIRLS VID screen shows that the Veteran is currently alive. A review of the record shows that the Veteran served in-country in the Republic of Vietnam.

The Veteran previously filed a claim for Pension benefits on May 10, 2009. On the Veteran‟s VA Form 21-526 the Veteran noted she was applying for Pension benefits only. The Veteran stated in the remarks section that her ischemic heart disease, which is due to service, is keeping her from working. A rating decision dated September 19, 2009, granted pension benefits using diagnostic code 7007 as the medical evidence showed the Veteran had a left ventricular dysfunction with an ejection fraction of 20 percent.

Questions

1) Is this a Nehmer case?

2) Is the Veteran entitled to retroactive compensation?

3) What effective date(s) should be assigned for retroactive compensation, if applicable?

4) Is any additional development necessary? If so, what development is required? If not, what is the next action?

VSR Scenario 5

A review of the record shows that the Veteran served in-country in the Republic of Vietnam.

The Veteran filed a claim for type II diabetes mellitus and hypertensive vascular disease in April 7, 1994. The Veteran was denied service connection for both conditions on September 21, 1994, using diagnostic codes 7913 and 7101. The evidence of record showed that the Veteran had a diagnosis of both conditions. Evidence showed that the Veteran was hospitalized 2 times for diabetes mellitus in 1993 for hypoglycemia. The Veteran was also on daily injections of insulin and on a restricted diet. The records also showed that the Veteran‟s blood pressure was 210/115 mmHg.

The Veteran filed a claim to reopen his type II diabetes claim and filed a new claim for ischemic heart disease on August 28, 1996. The claim was again denied on February 15, 1997. The evidence showed that the Veteran required 2 daily injections of insulin and now required daily dialysis due to chronic renal failure. Additionally, the evidence showed that a workload of 2 Metabolic Equivalents (METs) resulted in dyspnea, fatigue, and dizziness and the Veteran‟s diastolic pressure was predominantly measured at 132 mmHg.

A review of the file shows that the Veteran passed away on October 8, 1998, with the primary cause of death listed as end-stage renal disease, with contributing cause of death as diabetes mellitus. The surviving spouse filed a claim for death pension benefits on December 8, 1998. The surviving spouse was granted death pension and is still receiving benefits. The evidence of record shows that the spouse was married continuously to the Veteran from May 8, 1981, until the Veteran‟s death. The record also shows that they never had children. The spouse has not remarried.

Questions

1) Is this a Nehmer case?

2) Are there retroactive benefits?

3) What effective date(s) should be assigned for retroactive compensation, if applicable?

4) Is surviving spouse entitled to additional death benefits? If so, what is the benefit and what is the effective date?

5) Is any additional development necessary? If so, what development is required? If not, what is the next action?

RVSR Scenario 1

Rater Joe receives a file that is marked ready for decision. The DD Form 214 shows the Veteran served in the Navy from June 1, 1962, to August 30, 1973. The file also includes a DPRIS request response showing dates of service in the Republic of Vietnam from August 10, 1970, to November 30, 1972.

The Veteran filed an original claim for service connection for IHD on April 3, 1998. Medical evidence was submitted showing a diagnosis of IHD. Evidence shows that, at the time of the claim, continuous medication was required and a workload of 8 Metabolic Equivalents (METs) resulted in dyspnea, fatigue, and dizziness. The Veteran was denied service connection and notified of the decision on August 17, 1998.

On December 23, 1998, the Veteran then filed a claim for Pension benefits. The Veteran listed IHD under conditions that contributed to his unemployability. Medical evidence dated December 20, 1998, was submitted with a Pension claim showing chronic congestive heart failure. Pension was granted effective December 23, 1998, with diagnostic code 7005.

The Veteran passed away on January 27, 1999, with the secondary cause of death listed as ischemic heart disease (IHD).

On, September 20, 2007, the surviving spouse of the Veteran filed a claim for Dependency and Indemnity Compensation (DIC) and was denied and notified on February 19, 2008, due to lack of evidence showing that IHD was caused by service.

VSR has confirmed that the surviving spouse is living and has not remarried since the death of the Veteran. Evidence of record shows they were married from 1990 until the date of death. No children are of record.

Questions

1) Is this a Nehmer case?

2) Are there any retroactive benefits payable?

3) What percentage(s) and effective date(s) should be assigned for retroactive compensation, if applicable?

4) What is the effective date for DIC, if applicable?

5) What is the next action?

RVSR Scenario 2

A case arrives at your desk for a rating decision. The BIRLS VID screen shows that the Veteran is currently alive.

A review of the record shows that the Veteran served in-country in the Republic of Vietnam and has a combined rating of 30 percent without dependents. The Veteran‟s current rating code sheet shows that she is rated 10 percent for type II diabetes mellitus (Agent Orange) and 20 percent for a left knee condition. Both conditions were granted effective May 17, 2002, the date the Veteran claimed these conditions.

The Veteran filed a claim for hairy cell leukemia (HCL) on January 10, 1985. The Veteran‟s claim was denied and notified on September 12, 1985, because the condition was not incurred nor aggravated by service and the condition was not caused by herbicide exposure. Diagnostic code 7700 was used to prepare the rating. Evidence received on January 10, 1985, shows the Veteran was diagnosed with inactive HCL with original diagnosis on November 12, 1984.

Questions

1) Is this a Nehmer case?

2) Is the Veteran entitled to retroactive compensation?

3) What percentage(s) and effective date(s) should be assigned for retroactive compensation, if applicable?

4) What is the next action?

RVSR Scenario 3

You receive a file identified as ready to rate. A DD Form 214 in the file shows the Veteran served in the Navy from February 2, 1960, to May 31, 1981, and that the Veteran received a Vietnam Service Medal. The dates of service were verified using a DPRIS request; however, in-country service was not verified.

The Veteran filed an original claim for service connection for PD on March 29, 2005. Medical evidence was submitted showing a diagnosis of PD. The Veteran was denied service connection on July 10, 2005, using diagnostic code 8002.

A review of the file shows that the Veteran passed away on October 8, 2006, with the contributory cause of death listed as Parkinson‟s disease (PD). The Veteran was not in receipt of benefits and did not have a claim pending at time of death.

A claim for burial benefits was submitted on October 15, 2006, from Jane Doe. The form indicated that she was not filing a claim for service-connected death. Jane also listed herself as the surviving spouse on the application. Evidence of record shows that Jane was the surviving spouse since 1979 and has not remarried since the date of death. No children are of record.

The claim for burial benefits was denied on February 20, 2006, as the Veteran was not in receipt of compensation or pension benefits and the location of death was noted as the decedent‟s residence. VA sent Jane VA Form 21-534 and the form was not returned.

Questions

1) Is this a Nehmer case?

2) Are there retroactive benefits?

3) What percentage(s) and effective date(s) should be assigned for retroactive compensation, if applicable?

4) Is Jane Doe entitled to burial benefits?

5) What is the effective date for DIC, if applicable?

6) What is the next action?

RVSR Scenario 4

A case arrives at your desk for a rating decision. The BIRLS VID screen shows that the Veteran is currently alive. A review of the record shows that the Veteran served in-country in the Republic of Vietnam.

The Veteran previously filed a claim for Pension benefits on May 10, 2009. On the Veteran‟s VA Form 21-526 the Veteran noted she was applying for Pension benefits only. The Veteran stated in the remarks section that her ischemic heart disease, which is due to service, is keeping her from working. A rating decision dated September 19, 2009, granted pension benefits using diagnostic code 7007 as the medical evidence showed the Veteran had a left ventricular dysfunction with an ejection fraction of 20 percent.

Questions

1) Is this a Nehmer case?

2) Is the Veteran entitled to retroactive compensation? Yes, a claim for pension is a claim for compensation. .

3) What percentage(s) and effective date(s) should be assigned for retroactive compensation, if applicable?

4) What is the next action?

RVSR Scenario 5

You receive a file for a rating decision. A review of the record shows that the Veteran served in-country in the Republic of Vietnam.

The Veteran filed a claim for type II diabetes mellitus and hypertensive vascular disease in April 7, 1994. The Veteran was denied service connection for both conditions on September 21, 1994, using diagnostic codes 7913 and 7101. The evidence of record showed that the Veteran had a diagnosis of both conditions. Evidence showed that the Veteran was hospitalized 2 times for diabetes mellitus in 1993 for hypoglycemia. The Veteran was also on daily injections of insulin and on a restricted diet. The records also showed that the Veteran‟s blood pressure was 210/115 mmHg.

The Veteran filed a claim to reopen his type II diabetes claim and filed a new claim showing a diagnosis of ischemic heart disease on August 28, 1996. The claim was again denied on February 15, 1997. The evidence showed that the Veteran required 2 daily injections of insulin and now required daily dialysis due to chronic renal failure. Additionally, the evidence showed that a workload of 2 Metabolic Equivalents (METs) resulted in dyspnea, fatigue, and dizziness and the Veteran‟s diastolic pressure was predominantly measured at 132 mmHg.

A review of the file shows that the Veteran passed away on October 8, 1998, with the primary cause of death listed as end-stage renal disease, with contributing cause of death as diabetes mellitus. The surviving spouse filed a claim for death pension benefits on December 8, 1998. The surviving spouse was granted death pension and is still receiving benefits. The evidence of record shows that the spouse was married continuously to the Veteran from May 8, 1981, until the Veteran‟s death. The record also shows that they never had children. The spouse has not remarried.

Questions

1) Is this a Nehmer case?

2) Are there retroactive benefits? .

3) What percentage(s) and effective date(s) should be assigned for retroactive compensation, if applicable?

4) Is surviving spouse entitled to additional death benefits? If so, what is the benefit?

5) What is the next action? Prepare rating and send to Authorization for award.

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TRAINING LETTER 10-06
Adjudicating Disability Claims Based on Herbicide Exposure from U.S. Navy and Coast Guard Veterans of the Vietnam Era

All VA Regional Offices Training Letter 10-06

SUBJ: Adjudicating Disability Claims Based on Herbicide Exposure from U.S. Navy and Coast Guard Veterans of the Vietnam Era

Purpose

The Compensation and Pension (C&P) Service is providing the following information and guidelines in order to promote regional office awareness, consistency, and fairness in the processing of disability claims based on herbicide exposure from Veterans with service in the U.S. Navy and Coast Guard during the Vietnam era.

Background

Department of Veterans Affairs (VA) regulations provide Veterans who served in the Republic of Vietnam with the presumption of herbicide exposure due to widespread use of Agent Orange and other herbicides during U.S. military operations within the country. This allows for service connection on a presumptive basis for certain diseases that are associated with such exposure. VA limits the presumption of exposure to Veterans who served on the ground or on the inland waterways of Vietnam and excludes Veterans who served aboard ships operating on Vietnam’s offshore waters. This limitation has been legally upheld by the court system. However, VA has become increasingly aware of evidence showing that some offshore U.S. Navy and Coast Guard ships also operated temporarily on Vietnam’s inland waterways or docked to the shore. Additionally, VA has recently acquired evidence showing that certain ships operated primarily on the inland waterways rather than offshore. Veterans who served aboard these ships qualify for the presumption of herbicide exposure. Assisting Veterans who served aboard these ships requires special claims processing steps that are explained in this training letter.

Adjudicating Disability Claims Based on Herbicide Exposure from U.S. Navy and Coast Guard Veterans of the Vietnam Era

I. Introduction
Legal Background

The Department of Veterans Affairs (VA) acknowledges the widespread use of tactical herbicides, such as Agent Orange, by the United States military during the Vietnam War and has extended a presumption of herbicide exposure to any Veteran who served on the ground or on the inland waterways of the Republic of Vietnam between January 9, 1962, and May 7, 1975. This policy represents VA’s interpretation of the statutory phrase “served in the Republic of Vietnam” found at 38 U.S.C.§ 1116(a)(1). The regulation implementing this interpretation at 38 C.F.R. § 3.307(a)(6)(iii) makes it clear that “duty or visitation in the Republic of Vietnam” is required to qualify for the presumption. This policy is grounded in the fact that aerial herbicide spraying was used within the land boundaries of Vietnam to destroy enemy crops, defoliate areas of enemy activity, and create open security zones around U.S. military bases.

A legal challenge to VA’s interpretation was brought before the United States Court of Appeals for Veterans Claims (CAVC) in Haas v. Nicholson (2006). The case sought to further extend the presumption of exposure to U.S. Navy Veterans who served aboard ships operating on Vietnam’s offshore waters. CAVC held that the presumption of exposure should be extended to U.S. Navy Veterans. VA filed an appeal on that decision and implemented a stay on adjudicating the numerous new claims resulting from it. The United States Court of Appeals for the Federal Circuit, in Haas v. Peake (2008), reversed the CAVC decision and held that VA’s policy of extending the presumption only to those Veterans who served on the ground or on the inland waterways of Vietnam was a reasonable and valid statutory interpretation.

The Haas court cases and the resulting claims have sensitized Compensation and Pension (C&P) Service to the issues related to herbicide exposure claims from U.S. Navy Veterans. As a result, there is a need to clarify current claims processing policies and procedures in order to assist this group of Veterans in an equitable and consistent manner.

U.S. Navy in Vietnam

The following summary of U.S. Navy and Coast Guard activities in Vietnam is intended to give regional office personnel background information on the service provided to our nation by these Veterans and to assist with understanding development procedures when processing their claims.

U.S. Navy and Coast Guard operations in the waters of Vietnam were primarily focused on providing gunfire support for ground troops and conducting interdiction patrols designed to disrupt the movement of enemy troops and supplies from North Vietnam into South Vietnam. Shipboard gunfire was directed at inland targets primarily by destroyers (designated by DD hull numbers) operating at varying distances off the Vietnam coast. It was used to protect U.S. Army and Marine ground forces and destroy enemy positions within gun range. The destroyers operated along the offshore “gun line” on a rotating basis for several days or weeks at a time and then returned to escorting larger ships at sea or to a safe port, such as Subic Bay in the Philippines, for replenishment. Support missions for ground troops and attacks on enemy positions were also conducted by U.S. Navy aircraft launched from aircraft carriers (designated by CV or CVA hull numbers) stationed at sea, generally from 30 to 100 miles off the Vietnam coast. The gun line ships and aircraft carriers, as well as their supply and support ships, are collectively referred to as the “Blue Water” Navy because they operated on the blue-colored waters of the open ocean.

Although some Blue Water Navy destroyers were involved with enemy interdiction, the majority of these operations were conducted by smaller vessels based along the coast or within the river systems of South Vietnam. These vessels are collectively referred to as the “Brown Water” Navy because they operated on the muddy, brown-colored inland waterways of Vietnam. In general, patrolling of close coastal waters and the larger rivers was conducted by 50-foot swift boats (designated by PCF hull numbers) while patrolling of smaller rivers and waterways was carried out by 30-foot river patrol boats (designated by PBR hull numbers). Swift boat units were stationed at coastal locations where major rivers flowed into the South China Sea, from the Cua Viet River near the demilitarized zone (DMZ), which divided North from South Vietnam, to the large Mekong River Delta system that dominated the southern landscape of South Vietnam. Swift boats and some larger vessels sought to prevent enemy movement and activity along the close coastal waters and major river arteries. The code name for this interdiction effort was “Operation Market Time.” The U.S. Navy was assisted in this mission by two types of U.S. Coast Guard Cutters. They included “patrol boat” cutters (designated by WPB hull numbers), which were 80-foot vessels that operated like Navy swift boats, and “high efficiency” cutters (designated by WHEC hull numbers), which were 300- foot vessels that could interdict enemy craft farther offshore. These patrol and high efficiency cutters operated from land-based units within Vietnam and did not rotate in and out of Vietnamese waters like the larger Blue Water Navy vessels did.

The smaller Navy river patrol boats generally operated within the Mekong River Delta region and were attached to the Mobile Riverine Force, which was a joint force comprised of Brown Water Navy vessels and the U.S. Army 9th Infantry Division. This area of operation was strategically important because it was located just south of Saigon, the capital of South Vietnam, and bordered Cambodia. During the war, the overthrow of the Saigon government was a major enemy objective. As a result, troops and materials from North Vietnam moved south along a hidden supply line within Cambodia, known as the Ho Chi Minh Trail, and then into the Mekong River Delta region of South Vietnam to mount attacks. An especially dangerous area of enemy activity within the delta was referred to as the Rung Sat Special Zone. The Mobile Riverine Force mission was to protect Saigon from enemy infiltration through this difficult delta terrain. The code name for this interdiction effort was “Operation Game Warden.” Numerous support ships were also involved in the delta interdiction activities, including supply landing craft vessels (designated by LST hull numbers); mobile barracks vessels (designated by APL hull numbers); and auxiliary repair craft vessels (designated by ARL hull numbers).

Although operations on the inland waterways of Vietnam were primarily conducted by Brown Water Navy and Coast Guard vessels, some larger Blue Water Navy vessels periodically entered inland waterways to provide gunfire support or deliver troops or supplies. Gunfire support for land-based or riverine operations was provided by destroyers that entered a river, such as the Saigon River in the southern delta area, as a means to get closer to enemy targets. Following these temporary inland waterway operations, destroyers would return to patrolling the offshore gun line or travel farther out to sea for aircraft carrier escort duty. A number of Blue Water Navy amphibious assault and supply vessels also periodically entered inland waterways to deliver troops for a combat mission or supplies for units stationed on the rivers.

II. Processing Guidelines for Regional Offices

Evidentiary Development

U.S. Navy and Coast Guard Veterans of Vietnam who file disability claims will generally fall into one of three categories: (1) those who served at land based naval support facilities, such as the U.S. Naval Support Activities at Da Nang, near the DMZ, or Vung Tau, near the Mekong River Delta, or with land-based Navy Seabee construction units at various locations throughout South Vietnam; (2) those who served with the Brown Water Navy aboard patrol and support vessels operating on the inland rivers, canals, estuaries, and close coastal waters of South Vietnam; or (3) those who served with the Blue Water Navy aboard large ships operating on the open offshore waters of South and North Vietnam.

Veterans who served on land at a naval support facility or with the Brown Water Navy qualify for the presumption of herbicide exposure and development should proceed to establish their land-based or inland waterway service. Keep in mind that Veterans who served aboard the larger patrol vessels conducting interdiction missions along the close coastal waters operated out of land bases. So, despite the coastal off-shore activities, the crew was land based. This was not the case with Blue Water Navy crews who lived aboard their ships.

In order for the presumption of exposure to be extended to a Blue Water Navy Veteran, development must provide evidence that the Veteran’s ship operated temporarily on the inland waterways of Vietnam or that the Veteran’s ship docked to the shore or a pier. In claims based on docking, a lay statement that the Veteran personally went ashore must be provided. Since there is no way to verify which crewmembers of a docked ship may have gone ashore, C&P Service has determined that the Veteran’s lay statement is sufficient. This is in keeping with 38 U.S.C. § 1154, which states that consideration shall be given to the places, types, and circumstances of a Veteran’s service, and with 38 C.F.R. § 3.159(a)(2), which states that lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. In claims based on docking, the circumstances of service have placed the Veteran in a position where going ashore was a possibility and the Veteran, by virtue of being there, is competent to describe leaving the ship and going ashore. The circumstances also establish credibility unless there is evidence to the contrary.

Although evidence that the Veteran’s ship docked, along with a statement of going ashore, is sufficient for the presumption of herbicide exposure, service aboard a ship that anchored temporarily in an open deep water harbor or port is not sufficient. C&P Service considers open water ports such as Da Nang, Cam Ranh Bay, and Vung Tau as extensions of ocean waters and not inland waterways. They are not similar to the rivers, canals, and estuaries that make up the inland waterway system. This is illustrated by a quote from the 1967 ship’s history of the USS Cleveland (LPD-7), which states: “Da Nang Harbor is easy to enter due to being open to the sea.” Blue Water Navy ships occasionally entered these open water harbors and anchored temporarily without docking to take on fuel from harbor barges. Sometimes ships would briefly anchor so that ranking officers could attend strategy meetings ashore. In such cases, a small boat manned by a crewmember referred to as a “coxswain” would usually ferry the officers ashore. Deck logs and ship’s histories will generally not provide names of personnel going ashore from anchorage. However, evidence that a claimant served as a coxswain aboard a ship at anchorage, along with a statement from the Veteran of going ashore, may be sufficient to extend the presumption of exposure.

Claims based on statements that exposure occurred because herbicides were stored or transported on the Veteran’s ship, or that the Veteran was exposed by being near aircraft that flew over Vietnam or equipment used in Vietnam, do not qualify for the presumption of exposure. These claims can be processed without further development by placing a memorandum for the record from the Army and Joint Services Records Research Center (JSRRC) in the claims file. This memorandum is located in M21-1MR at IV.ii.2.C.10.l and states that JSRRC research efforts have been unable to provide evidence supporting such claims of shipboard herbicide exposure.

When a U.S. Navy Veteran claims herbicide exposure based on inland waterway service or shore docking, development begins with a PIES O19 request for military records and a PIES O34 request for dates of service in Vietnam, both sent to the National Personnel Records Center. Information from these requests should provide the name of the Veteran’s ship, dates of service aboard it, and dates the ship operated on the offshore waters of Vietnam. This information may be sufficient to establish exposure without extensive development.

The first reference to check is the new Vietnam Era Navy Ship Agent Orange Exposure Development Site located on the C&P Service Intranet site located under Rating Job Aids. The site contains several links. The Ships operating on the inland waterways or docking in Vietnam link identifies: (1) Brown Water Navy individual vessels, and types of vessels, that operated primarily or exclusively on the inland waterways, and (2) Blue Water Navy individual vessels that temporarily operated on inland waterways or docked, with dates. The activity of all these ships has been verified through official documents or websites. If the Veteran served aboard one of the listed Brown Water Navy vessels at any time during its Vietnam tour, the presumption of exposure applies. For Veterans serving aboard one of the listed Blue Water Navy vessels, the presumption will apply only if the Veteran was aboard during the specified dates. The ships are arranged by vessel type and hull number and can be searched by name through use of the “Find” tool under the “Edit” function on your personal computer tool bar. Another link is to the official U.S. Navy Dictionary of American Naval Fighting Ships (DANFS) website. This site provides ship histories for most naval vessels. Ships are listed alphabetically by name. The histories vary in completeness but some provide detailed descriptions of service on Vietnam’s inland waterways, whether operating as part of the permanent Mobile Riverine Force or operating temporarily on gunfire support or supply missions. Since DANFS is an official U.S. Navy site, evidence from it supporting the claim will generally be sufficient to establish the presumption of herbicide exposure. A third link is to U.S. Naval Bases & Support Activities Vietnam. This site provides a description of all land-based locations that supported U.S. Navy operations in Vietnam. It is not an official government site but can serve as a valuable starting point for research if the name of one of these bases, or units located there, appears in the claims file or is identified by the Veteran.

An additional location to check is the Stressor Verification Site, which is also on the C&P Service Intranet under Rating Job Aids. This site has a section with official declassified documents on Navy operations in Vietnam and may provide information on inland waterway activity or docking for specific vessels. It also contains information on Brown Water Navy and Seabee construction operations.

If these sources do not provide evidence to support the claimed exposure, development should proceed with a DPRIS O43 request to JSRRC for information on the Veteran’s ship. JSRRC has recently agreed to expand its research on the ship’s history to include deck log research. It will no longer be necessary to request deck logs from the National Archives and Records Administration. JSRRC will review the ship’s official history for a record of inland water operations or docking and, if this does not provide supporting evidence, will then review deck logs for the time frame identified by the Veteran. The time frame must be limited to 60 days but can include different date ranges, as long as the cumulative time frame does not exceed 60 days. The DPRIS request screen will accept two date ranges for a single ship under “Dates Ship was in RVN Territorial Waters.” If additional date ranges are required for the same ship, type them into the large space for “Circumstances Surrounding Exposure to Agent Orange.” In that space, also describe the Veteran’s statement as to how exposure occurred. JSRRC will provide a summary of its findings for the time frames requested.

When the JSRRC response is received, evaluate it carefully for evidence of the vessel’s entry into the inland waterways or docking. Although JSRRC does not provide copies of all original document reviewed, relevant excerpts are generally included with the summary. When evaluating deck log information, look for statements like “maneuvering at various speeds into…” and references to such locations as “Cua Viet River,” “Saigon River,” “Mekong River Delta,” and “Ganh Rai Bay” or “Rung Sat Special Zone” (both are up river from Vung Tau Harbor). Keep in mind that anchoring in one of these locations is not the same as anchoring in an open deep-water port; these are inland waterways and the presumption of exposure applies to any anchorage associated with them. When deck logs refer to entering or anchoring in the “mouth” of one of these locations, or any other identifiable river location, C&P Service has determined that this is sufficient to establish service on the inland waterways. It is not practical to establish a bright dividing line between a river entrance and the South China Sea. Therefore, the benefit-of-the-doubt doctrine is applicable and evidence of the vessel’s presence in a river’s mouth is sufficient to establish the presumption of exposure for Veterans aboard that ship.

Ratings Procedures

When development is complete, a rating decision can be produced. Service connection will depend on whether the evidence confirms that the Veteran served at a land-based Navy facility within Vietnam, with the Brown Water Navy on the inland waterways of Vietnam, or aboard a Blue Water Navy ship that operated temporarily on the inland waterways or docked to the shore. If service connection is granted, a disability percentage determination may be possible based on medical evidence already in the claims file from a private physician or a treating VA medical facility. If the available medical evidence is insufficient to determine the level of disability, a VA examination is necessary.

The next issue for consideration is the effective date for compensation purposes. For an original claim, the effective date will be the date VA receives the claim or the date entitlement arose, whichever is later, as stated in 38 C.F.R. § 3.400. Since all the presumptive diseases associated with herbicide exposure represent liberalizing regulations, 38 C.F.R. § 3.114 will also apply. This means that the effective date for compensation may go back one year prior to the date of claim, if evidence shows that the disease was present at that time. However, the effective date may not go back earlier than the date that the disease itself was added by regulation to the list of herbicide exposure-related diseases.

Due to the Haas decision, the majority of Navy Veterans’ cases will likely involve a previous denial and either a claim to reopen received from the Veteran or a review initiated by VA. In these cases, reopening the claim may be based on new and material evidence showing inland waterway service or docking found in deck logs, ship histories, or some other acceptable documentation. If service connection is granted, the effective date will generally be governed by 38 C.F.R. § 3.156(c) because the newly acquired evidence falls under “service department records” and meets the regulatory requirements of: (1) official service department records, (2) existing at the time VA decided the claim, and (3) not associated with the claims file at that time. In cases where these records have now become available and are associated with the claims file, the regulation provides for a reconsideration of the claim.

If the evidence justifies service connection, the effective date will be the date entitlement arose or the date VA received the previously decided claim, whichever is later, as stated in section 3.156(c)(3). This is the general rule, but there are several factors to consider. The date entitlement arose may be either the date that the claimed disease was diagnosed (or symptoms became manifest according to medical evidence) or the date that the claimed presumptive disease was finalized as part of the presumptive list of herbicide exposure-related diseases at 38 C.F.R. 3.309(e). The date entitlement arose cannot precede the date a presumptive disease was added to the regulations.

Consideration must be given to the date of receipt of the original denied claim in relationship to the date that the claimed disease was finalized as part of the herbicide exposure presumptive list. If the original denied claim was received prior to addition of the claimed disease to the presumptive list and the evidence now warrants service connection, the effective date will be the date the disease was added to the presumptive list. If the original denied claim was received after the claimed disease was added to the presumptive list and the evidence now warrants service connection, the effective date will be the date the original denied claim was received or the date that medical evidence shows the Veteran first contracted the claimed disease, whichever is later, in accordance with section 3.156(c)(3). However, in such cases, section 3.114 will also apply because the additions of new presumptive diseases are regulatory liberalizations. Therefore, if the original denied claim was received within one year of the date the claimed disease was added to the presumptive list, and the claimed disease was present at that time, the effective date will be the date of that addition. If the claim was received more than one year after the claimed disease’s addition, the effective date will be one year prior to the date it was received, if the claimed disease was present at that time.

If, for example, an original denied claim for diabetes mellitus (DM) type 2 was received before May 8, 2001, the date that DM type 2 was added to the list of diseases associated with herbicide exposure, the effective date for compensation could be no earlier than May 8, 2001. If the original denied claim for DM type 2 was received any time within the one-year period following May 8, 2001, the effective date for compensation would go back to May 8, 2001. If, on the other hand, the original denied claim was received more than one year after May 8, 2001, the effective date for compensation would go back one year from the date of claim. Another situation may arise where the Veteran has filed two claims for DM type 2, one before May 8, 2001, and the other more than one year after, both of which were denied. If readjudication evidence now shows that herbicide exposure can be presumed, the earlier denied claim should be used to determine the effective date for compensation, which would be the date that DM type 2 was added to the presumptive list. This effective date scheme assumes in all cases that the Veteran’s disease was present on the date of claim, as required by section 3.114. The date that each presumptive disease associated with herbicide exposure was added to section 3.309(e) can be found in M21-1MR at IV.ii.2.C.10.i.

Regulations concerning awards and effective dates related to the Nehmer court case are found at 38 C.F.R. § 3.816. These will apply to the latest proposed diseases to be associated with herbicide exposure: ischemic heart disease, Parkinson’s disease, and chronic B-cell leukemias, as explained in C&P Service Training Letter 10-04.

Herbicide-related disability claims from Navy Veterans of the Vietnam era were generally denied because the evidence available did not verify their service on the ground in Vietnam or on its inland waterways at the time of the decision. Therefore, section 3.156(c) governs effective date issues when the records of inland waterway service or shore docking have become available.

Additional Considerations

Regional office personnel should keep in mind that when a Blue Water Navy Veteran claims non-Hodgkin’s lymphoma as a disability, service connection may be granted without the need to show inland waterway service or docking. Although this disease is on the herbicide exposure-related list at section 3.309(e), it is also specified as a presumptive disease at 38 C.F.R. 3.313, based solely on “service in Vietnam ” without reference to herbicide exposure. Therefore, any Veteran who served in the offshore waters of Vietnam will qualify for this presumption when this disease manifests itself subsequent to service.

Regional office personnel should also be aware that it is not proper to propose severing service connection for Blue Water Navy Veterans who were granted a presumption of herbicide exposure under former policies. Before the Haas case entered the court system, there was a short period of time when a Blue Water Navy Veteran’s receipt of the Vietnam Service Medal was considered sufficient to establish a presumption of herbicide exposure. That broad policy was subsequently narrowed so that service on the ground in Vietnam or on its inland waterways was required to receive a presumption of exposure. The Haas case was initiated as a challenge to the revised policy. Although the final judicial decision in Haas supported VA’s revised policy, that decision cannot be applied retroactively to Veterans who were evaluated under the original broad policy. In the CAVC case of Berger v. Brown (1997), the court stated that its holdings, which formulate new interpretations of the law subsequent to regional office decisions, cannot be used as the basis for a clear and unmistakable error (CUE) action. Additionally, the Federal Circuit, in Jordan v. Nicholson (2005), held that if VA correctly applied a regulation (or policy) in a prior final decision, the fact that the regulation (or policy) was later found to be invalid does not establish that the prior final decision contained CUE warranting retroactive correction. Therefore, if a Blue Water Navy Veteran was previously awarded presumptive service connection based on herbicide exposure when the broad standard was in effect, that service connection cannot now be severed.

www.howtoassemblevaclaims.comA free guide on how to research, organize and assemble a VA claim, now
upgraded to include suggestions for VONAPP and Social Security
Disability.

Veterans are the mainstay of this country. Only they truly know the price of freedom. Only they can truly teach others like
myself the price of freedom.

Another Suggestion to Help Veterans...

For those with too much time on their hands, check out table board hobbies; i.e., Warhammer 40,0000;
Dungeons & Dragons; and others of their ilk. These provide varied and interesting features:

SUBJ: Adjudication of Claims for Total Disability Based on Individual Unemployability (TDIU)

PURPOSE

Our purpose in issuing this training letter is to revise and clarify our policies and procedures concerning the adjudication of TDIU decisions in order to restore the original intention of the TDIU evaluation – accurately, timely, and adequately compensating our Veterans who are unable to be gainfully employed due to service-connected disabilities.

BACKGROUND

VA has a longstanding and well-established policy of granting total disability ratings to Veterans who, due to service-connected disability(ies), are unable to secure and maintain substantially gainful employment even if a Veteran’s combined disability evaluation does not result in a total schedular evaluation. The provisions of 38 C.F.R. § 4.16(a) provide the minimal schedular standards for TDIU consideration: if there is one disability, this disability shall be ratable at 60 percent or more; and, if there are two or more disabilities, there must be at least one disability ratable at 40 percent or more and additional disability to bring the combined rating to 70 percent or more. Alternatively, if these schedular requirements are not met, but the evidence shows the Veteran is unemployable due to service-connected disabilities, 38 C.F.R. § 4.16(b) authorizes VA to grant a TDIU evaluation on an extra-schedular basis upon approval by the Director, Compensation and Pension Service.

In recent years, several factors, including internal inconsistencies in developing and adjudicating TDIU decisions and changing policies and procedures issued in response to court decisions addressing the TDIU issue, have led to a conclusion that the TDIU issue requires new guidance. A review of TDIU grants has also revealed that the benefit is, at times, granted on a quasi-automatic basis when the Veteran attains a certain age and/or schedular rating. This practice is not supported by VA regulation or policy.

History of TDIU Evaluations

The regulatory history does not provide an explanation for the creation of TDIU ratings. VA’s 1933 Schedule for Rating Disabilities (VASRD) provided the first definition of total disability as existing “when there is (or are) present any impairment (or impairments) of mind or body which is (or are) sufficient to render it impossible for the average person to follow a substantially gainful occupation.” A 1934 revision of the VASRD provided the first authorization of a TDIU rating, sanctioned total disability ratings “without regard to the specific provisions of the rating schedule if a Veteran with disabilities is unable to secure or follow a substantially gainful occupation as a result of his disabilities.”

In 1941, the Administrator of Veterans Affairs issued an extension of the 1933 VASRD, which provided that total disability ratings may be assigned without regard to the specific provisions of the rating schedule when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of his/her disabilities. The 1941 regulation also provided the current TDIU rating criteria.

The 1945 Schedule for Rating Disabilities established that age may not be considered a factor in evaluating service-connected disability, and that service-connected unemployability could not be based on advancing age or additional (nonservice-connected) disability. (Paragraph 16, General Policy in Rating Disability)

38 C.F.R. § 4.16(a) became effective in March 1963. The regulation was amended in September 1975 to include subsection (b), which authorized a TDIU evaluation on an extra-schedular basis. In March 1989, subsection (c) was added to § 4.16, which directed that if a Veteran was rated 70 percent for a mental disorder that precluded gainful employment, 38 C.F.R. § 4.16(a) was not for application and such Veteran was to be assigned a 100-percent schedular evaluation.

In August 1990, 38 C.F.R. § 4.16(a) was revised to include language that marginal employment would not be considered gainful employment and also provided a definition of what constituted marginal employment. Following VA’s adoption of the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders, 38 C.F.R. § 4.16(c) was rescinded in October 1996. The provision was now viewed as being extraneous, as a Veteran with a service-connected mental disorder would not be disadvantaged with the application of the other subsections of 38 C.F.R. § 4.16.

Case Law

The Court of Appeals for Veterans Claims (CAVC) and the Court of Appeals for the Federal Circuit (Federal Circuit) have issued many precedent opinions that have substantively affected Veterans’ rights associated with TDIU evaluations, as well as how VA adjudicates the issue. Below are some of the most pertinent holdings in decisions concerning TDIU from both courts.

Moore v. Derwinski, 1 Vet.App. 83 (1991) The term “substantially gainful occupation” refers to, at a minimum, the ability to earn a living wage.

Blackburn v. Brown, 4 Vet.App. 395 (1993) Entitlement to TDIU compensation must be established solely on the basis of impairment arising from service-connected disabilities.

Hattlestad v. Brown, 5 Vet.App. 524 (1993) In determining entitlement to TDIU evaluations, a clear explanation requires analysis of the current degree of unemployability attributable to the service-connected condition as compared to the degree of unemployability attributable to the non-service connected condition.

Norris v. West, 12 Vet.App. 413 (1999) When VA is considering a rating increase claim from a claimant whose schedular rating meets the minimum criteria of § 4.16(a) and there is evidence of current service-connected unemployability in the claims file or under VA control, evaluation of that rating increase must also include an evaluation of a reasonably raised claim for TDIU.

Faust v. West, 13 Vet.App. 342 (2000) In determining entitlement to a TDIU rating, VA must consider the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. A determination of whether a person is capable of engaging in a substantially gainful occupation must consider both that person’s abilities and employment history.

Hurd v. West, 13 Vet.App. 449 (2000) A TDIU claim is a claim for increased compensation, and the effective date rules for increased compensation apply to a TDIU claim.

Roberson v. Principi, 251 F.3d 1378 (2001) Once a Veteran submits evidence of a medical disability, makes a claim for the highest rating possible, and submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim “identify the benefit sought” has been satisfied and VA must consider whether the Veteran is entitled to TDIU.

Bradley v. Peake, 22 Vet.App. 280 (2008) The provisions of 38 U.S.C. § 1114(s) do not limit a “service-connected disability rated as total” to only a schedular 100-percent rating. A TDIU rating may serve as the “total” service-connected disability, if the TDIU entitlement was solely predicated upon a single disability for the purpose of considering entitlement to SMC at the (s) rate.

Comer v. Peake, 552 F.3d 1362, 1367 (Fed. Cir. 2009) A claim for a total disability evaluation due to individual unemployability (TDIU) is implicitly raised whenever a pro se Veteran (unrepresented), who presents cogent evidence of unemployability, seeks to obtain a higher disability rating, regardless of whether the Veteran specifically states that he is seeking TDIU benefits.

Rice v. Shinseki, 22 Vet.App. 447 (2009) A request for a total disability evaluation on the basis of individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate claim for benefits, but involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or as part of a claim for increased compensation, if entitlement to the disability upon which TDIU is based has already been found to be service connected. There is no freestanding TDIU claim.

Processing

VA has historically handled TDIU claims as freestanding claims that were adjudicated separately from other compensation issues in its decisions. However, as a result of the Rice decision, a request for TDIU, whether specifically raised by the Veteran or reasonably raised by the evidence of record, is no longer to be considered as a separate claim but will be adjudicated as part of the initial disability rating or as part of a claim for increased compensation.

The current Veterans Claims Assistance Act (VCAA) notice letters used for original disability compensation claims or claims for increased evaluation are sufficient if a request for a TDIU evaluation is introduced. A separate notice letter for a TDIU evaluation is no longer required. If a VA Form 21-8940, Veteran’s Application for Increased Compensation based on Unemployability, or other submission expressly requests TDIU, this will be considered a claim for increased evaluation in all service-connected disabilities unless TDIU is expressly claimed as being due to one or more specific disabilities. The initial notice letter will provide VCAA compliant information for all service-connected disabilities that are not currently evaluated at the schedular maximum evaluation for that condition.

The principle of staged ratings may be applied in considering the effective date for a TDIU evaluation as either part of the initial disability evaluation or as part of a claim for increase. See Fenderson v. West, 12 Vet.App. 119 (1999); Hart v. Mansfield, 21 Vet.App. 505 (2007).

VA Forms 21-8940 and 21-4192

Notwithstanding any favorable medical evidence or opinion indicating that the Veteran is unemployable due to service-connected disabilities, a TDIU evaluation may not be granted if the evidence otherwise shows that the Veteran is engaged in, or capable of being engaged in, gainful employment. Accordingly, a VA Form 21-8940, Veteran’s Application for Increased Compensation based on Unemployability, should still be forwarded to the Veteran if a request for a TDIU evaluation is expressly raised by the Veteran or reasonably raised by the evidence of record.

The VA Form 21-8940 remains an important vehicle for developing the claim and determining entitlement to a TDIU evaluation. However, the determination of an effective date for the establishment of a TDIU evaluation is no longer primarily based upon the date of receipt of the VAF 21-8940, but upon consideration of other factors such as the date of the original claim or claim for increase and the date that the evidence establishes inability to maintain substantially gainful employment due to service-connected disability(ies).

Once the VA Form 21-8940 is received and former employers are identified, then VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefit, will be forwarded to the former employers listed on the form. The VA Form 21-4192 requests that the employer provide information about the Veteran’s job duties, on-the-job concessions, date of and reason for job termination, etc. A TDIU evaluation should not be denied solely because an employer failed to return a completed VA Form 21-4192.

VA Form 21-8940, while still important as a development tool, is not required to render a decision concerning whether or not to assign a TDIU evaluation. A decision concerning entitlement to a TDIU evaluation may be rendered without a completed VA Form 21-8940 of record, based on the entire body of evidence available.

Examinations

VA examinations are generally undertaken in conjunction with original disability compensation claims and claims for increase in accordance with VA’s statutory duty to assist a Veteran in developing his/her claim. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). In such claims, if a request for a TDIU evaluation is expressly raised by the Veteran or reasonably raised by the evidence of record, a general medical examination is to be scheduled. Specialty examinations (Eye, Audio, Mental, Traumatic Brain Injury, and Dental) may also need to be scheduled. These specialty examinations are only to be ordered when the Veteran is service connected for an eye, audio, mental, or dental condition that is not already at the schedular maximum, even if this condition is not one that the Veteran is claiming as causing his or her unemployability. Additionally, the examiner should be requested to provide an opinion as to whether or not the Veteran’s service-connected disability(ies) render him or her unable to secure and maintain substantially gainful employment, to include describing the disabilities’ functional impairment and how that impairment impacts on physical and sedentary employment.

In applying the Court’s holding in Bradley, if the medical evidence is insufficient to render an adjudicative determination as to whether the Veteran’s TDIU entitlement solely originates from a single service-connected disability, and there is potential entitlement to SMC at the (s) rate, the VA examination should also include an opinion as to what disability or disabilities render the Veteran unable to secure and maintain substantially gainful employment.

Other TDIU Development Considerations

If the evidence indicates that the Veteran has been seen by the Vocational Rehabilitation and Employment Service (VR&E) or has applied for disability benefits from the Social Security Administration (SSA), these records, to include any decisions and supporting documentation, must be obtained.

The Rating Decision

Although TDIU is no longer a freestanding claim, the determination of entitlement to a TDIU evaluation, raised as part of an original claim or claim for increased evaluation, must still be disposed of as a separate issue in the rating decision.

In assigning the effective date for a TDIU evaluation, the regulations concerning effective dates for original claims and claims for increase – 38 C.F.R. §§ 3.400(b)(2) or (o) – will be applied. Also, when a TDIU evaluation is assigned, the evidentiary record should be carefully reviewed to determine the applicability of 38 C.F.R. § 3.156(b), whether as part of an initial disability rating or as part of a claim for increase. 38 C.F.R. § 3.157 may be applicable in claims for increased evaluation that also raise a request for a TDIU evaluation. (For further guidance, see our Decision Assessment Document in Rice v. Shinseki, May 6, 2009).

In compliance with the Bradley holding, if TDIU is granted, a determination must also be rendered as to what specific service-connected disability(ies) render the Veteran unemployable. Generally, there would have to be clear and substantial evidence to show that unemployability is caused by a single disability when there are multiple serviceconnected disabilities. In original disability claims, where service connection is not established for any disability, the issue of entitlement to a TDIU evaluation is rendered moot, unless specifically claimed.

When establishing an end product for TDIU, it will be adjudicated as part of the initial disability rating or as part of a claim for increase. If a claim for TDIU is received after development has been initiated, to include VCAA notification, and a determination of entitlement to service connection for the disability upon which TDIU is based is still pending or has not been found, adjudicate the TDIU issue under the existing end product.

In situations where TDIU is inferred and additional evidence is needed, rate all other claimed issues that can be decided before rending a decision on TDIU entitlement. Show the issue of potential TDIU entitlement as deferred in the rating decision. Develop the inferred TDIU issue under the existing or appropriate end product, which will remain pending. Send the Veteran a VA Form 21-8940 to complete and return. Every inferred TDIU request that is deferred for additional evidence must be resolved by a formal rating decision after the evidence is received or the notification period expires. See Fast Letter 08-06 (February 27, 2008).

Whenever a rating decision grants TDIU and establishes permanency, it must include the statement, “Basic eligibility under 38 U.S.C. Chapter 35 is established from [date].” This statement is required regardless of whether or not there are potential dependents.

Continuing Requirements for the TDIU Award

As inability to maintain substantially gainful employment constitutes the basic criteria that must be satisfied for a TDIU evaluation, after the initial TDIU grant is awarded, VA must continue to ensure that the Veteran is unemployable.

Therefore, the Veteran must complete and return a VA Form 21-4140, Employment Questionnaire, annually for as long as the TDIU evaluation is in effect. Yearly submission of the form is required unless the Veteran is 70 years of age or older, or has been in receipt of a TDIU evaluation for a period of 20 or more consecutive years (See 38 C.F.R. § 3.951(b)), or has been granted a 100-percent schedular evaluation. The form is sent out annually to the Veteran from the Hines Information Technology Center and must be returned to the regional office. It requests that the Veteran report any employment for the past twelve months or certify that no employment has occurred during this period. The VA Form 21-4140 must be returned within 60 days or the Veteran’s benefits may be reduced. If the form is returned in a timely manner and shows no employment, then the TDIU evaluation will continue uninterrupted. The VA Form 21-4140 must be returned with the Veteran’s signature certifying employment status. A telephone call to the Veteran is not acceptable to certify employment status for TDIU claims.

If the VA Form 21-4140 is timely returned and shows that the Veteran has engaged in employment, VA must determine if the employment is marginal or substantially gainful employment. If the employment is marginal, then TDIU benefits will continue uninterrupted. If the employment is substantially gainful, then VA must consider discontinuing the TDIU evaluation. 38 C.F.R. § 3.343(c)(1) and (2) provide that actual employability must be shown by clear and convincing evidence before the benefit is discontinued. Neither vocational rehabilitation activities nor other therapeutic or rehabilitative pursuits will be considered evidence of renewed employability unless the Veteran’s medical condition shows marked improvement. Additionally, if the evidence shows that the Veteran actually is engaged in a substantially gainful occupation, the TDIU evaluation cannot be discontinued unless the Veteran maintains the gainful occupation for a period of 12 consecutive months. See 38 C.F.R. § 3.343(c).

Once this period of sustained employment has been maintained, the Veteran must be
provided with due process before the benefit is actually discontinued, as stated at 38 C.F.R. §§ 3.105(e) and 3.501(e)(2). This consists of providing the Veteran with a rating that
• Proposes to discontinue the IU benefit
• Explains the reason for the discontinuance
• States the effective date of the discontinuance, and
• States that the Veteran has 60 days to respond with evidence showing why the discontinuance should not take place.

If the TDIU evaluation is discontinued, the effective date of the discontinuance will be the last day of the month following 60 days from the date the Veteran is notified of the final rating decision. If the VA Form 21-4140 is not returned within the 60 days specified on the form, then the regional office must initiate action to discontinue the TDIU evaluation pursuant to 38 C.F.R. § 3.652(a). Due process must also be provided with a rating decision that proposes to discontinue the TDIU benefit for failure to return the form. If a response is not received within 60 days, then the TDIU evaluation will be discontinued and a rating decision will be sent to the Veteran providing notice of the discontinuance. The effective date of discontinuance will be the date specified in the rating decision which proposed discontinuance, as described above, or the day following the date of last payment of the TDIU benefit, as specified at § 3.501(f), whichever is later. The Veteran must also be notified that if the form is returned within one year and shows continued unemployability, then the TDIU evaluation may be restored from the date of discontinuance.

VA may also use the income verification match (IVM) to verify continued unemployability. The IVM is a method of comparing a TDIU recipient’s earned income, as reported to VA by other federal agencies, with the earned income limits that define marginal employment. If income reports show significant earned income above the poverty threshold, the regional office must undertake development to determine if the Veteran is still unemployable. IVM information does not meet the requirements for a completed VA Form 21-4140 for the purpose of continuing TDIU benefits. A completed VA Form 21-4140 still must be provided by the Veteran for continuation of TDIU benefits.

Another method of monitoring unemployability status among TDIU recipients is through the VA Fiduciary Activity. This service conducts field examinations when it has been notified that a TDIU recipient might be pursuing a substantially gainful occupation. If the field examiner finds evidence of employment or if the Veteran is unwilling to cooperate with the examiner, then the examiner will forward this information to the Rating Activity. A decision must then be made as to whether the TDIU evaluation will be discontinued. The regulatory requirements listed above will be applied to the determination.

As an exception to the aforementioned procedures; if the veteran has certified no employment status in a VA Form 21-4140 and VA obtains credible information indicating that the veteran has engaged in gainful employment, continued entitlement to TDIU benefits may be terminated on the basis of fraud. The due process provisions of § 3.105(e) must still be followed. However, if a finding of fraud is confirmed, the effective date of termination of TDIU benefits will be the day preceding the date that VA received the veteran’s VA Form 21-4140 that fraudulently certified continuation of no employment status. See 38 C.F.R. § 3.500(k).

Scenarios

Below are several factual scenarios intended to illustrate how claims involving requests for TDIU evaluations should be developed and rated, as well as the appropriate regulations to be applied in determining the effective date of the TDIU evaluation.

(1) A Veteran files a claim for service connection for PTSD in January 1999. The RO grants service connection in November 1999 with a 50-percent evaluation. The Veteran files a Notice of Disagreement (NOD) with the evaluation and submits a VAF 21-8940 in February 2000 indicating that he has been unable to work due to PTSD. The RO, in September 2000, grants a 70-percent evaluation for PTSD from January 1999 and also assigns a TDIU evaluation effective January 1999.

In this scenario, the TDIU evaluation is considered as part of the initial disability rating, not a freestanding TDIU claim. 38 C.F.R. § 3.156(b) is applicable as the Veteran had submitted evidence of unemployability within the appeal period and 38 C.F.R. § 3.400(b)(2) will be applied in determining the effective date of the TDIU evaluation.

(2) The Veteran has been service connected for several disabilities, to include migraine headaches, since 2001. In March 2006, he/she submits a claim for increased evaluation for migraine headaches, rated 10-percent disabling at the time, stating that the frequency and severity of his migraine headaches have worsened. The RO issues a decision in December 2006 granting a 50-percent evaluation from March 2006. His/her combined disability evaluation is also increased to 70 percent. The Veteran timely files an NOD in response to the evaluation assigned for migraine headaches and appears before a Decision Review Officer (DRO) in an informal conference. He/she submits a VAF 21-8940, additional medical evidence, and a letter from his/her employer indicating that the Veteran was unable to continue working because he/she missed too much time because of his/her migraine headaches and last worked in March 2006. The DRO, in February 2007, grants a TDIU evaluation effective March 2006.

In this scenario, the TDIU evaluation is considered as part of the claim for increased compensation. 38 C.F.R. § 3.156(b) is applicable as the Veteran had submitted evidence within the appeal period and 38 C.F.R. § 3.400(o) will be applied in determining the effective date. The effective date for the TDIU evaluation will be based upon the date it is factually ascertainable that the Veteran was unable to maintain substantially gainful employment due to his service-connected disability(ies), to include up to one year prior to the date of the March 2006 claim for increased evaluation under § 3.400(o)(2).

(3) The Veteran is service connected for post traumatic stress disorder (PTSD), rated 50-percent disabling; arthritis of the knees, each rated 10-percent disabling; and several other disabilities that have been assigned noncompensable evaluations. He files a claim for increased evaluation for PTSD, stating that the condition has worsened and that he had to discontinue working due to problems associated with the condition. He submits medical evidence and identifies VA medical records that only concern treatment for PTSD and show difficulty in maintaining employment due to the mental disorder.

A VCAA notice for the PTSD evaluation and TDIU and a VA Form 21-8940 should be forwarded to the Veteran. The notice should not refer to the other service-connected disabilities, as the Veteran specifically indicated that only PTSD has rendered him unemployable. A general medical examination with a special psychiatric examination for PTSD is to be requested. The VA examiner should be requested to render an opinion concerning the effect of PTSD on employability as a request for a TDIU evaluation has been reasonably raised by the Veteran and the evidence of record.

(4) The Veteran has been service connected for ankylosing spondylitis, rated 60-percent disabling; eczema, rated 30-percent disabling; and hiatal hernia, rated 10-percent disabling, since 2003. In January 2007, he submits a statement indicating that he cannot work due to his service-connected disabilities.

In this scenario, the correct course of action is to send the Veteran a VCAA notice for claims for increased evaluation that pertain to all service-connected disabilities not currently at the schedular maximum evaluation, as the Veteran did not specifically state what service-connected disability(ies) affects his employability.

The Veteran should be scheduled for a general medical examination that also includes an opinion as to whether or not the service-connected disability(ies) render the Veteran unable to secure and maintain substantially gainful employment.

BACKGROUND INFORMATION
TL 06-03, titled "Traumatic Brain Injury," was issued in February 2006. It provided extensive medical information about the causes of traumatic brain injury (TBI), especially as related to combat, the anatomy and physiology of the brain, signs and symptoms of TBI, grades of severity of TBI, the course of recovery and consequences of TBI, and disabilities resulting from TBI. It also provided some basic rating information about TBI.

TL 07-05, titled "Evaluating Residuals of Traumatic Brain Injury," was issued in August 2007. It provided additional information about the specifics of rating TBI. However, that material is now obsolete in part because of the new regulation, and parts of TL 07-05 have been superseded by TL-09-01.

CURRENT EFFORTS
This training letter provides new information and guidance about evaluating TBI, based on the regulation revising diagnostic code 8045 in the "Neurological conditions and convulsive disorders" section of the rating schedule (38 CFR 4.124a) that was published in the Federal Register on September 23, 2008 (73 FR 54693-54708). It also provides the common definition of TBI that was jointly developed by VA and the Department of Defense.

WHO TO CONTACT FOR HELP
Questions should be e-mailed to the Q&A Committee.

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Compilation of PDA Guidance and Policies
Current as of 25 MAR 2010

New Criteria for Evaluating Residuals of Traumatic Brain Injury

A. Introduction

New criteria for evaluating the residuals of traumatic brain injury (TBI) under diagnostic code 8045 have been published. Therefore, we are issuing this training letter to explain the revised criteria and their application.

This letter also provides and explains the common VA and Department of Defense (DoD) definition of TBI, which was developed by the DoD/VA Definition and Taxonomy Working Group and other joint consensus panels.

This letter supersedes the guidance for evaluating residuals of mild TBI and the discussion of the
assessment of cognitive impairment that were provided in TL 07-05.

B. Definition of TBI

VA and DoD have developed and approved a common definition of TBI that is now in general use by both departments. It establishes a common definition of TBI, severity of brain injury stratification, and method of data collection.

Both Departments use the common DoD/VA definition as the foundation of data systems, policies, and regulations.

Part I of definition: VA/DoD Common Definition of TBI

A traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event:

Any period of loss of or a decreased level of consciousness;

Any loss of memory for events immediately before or after the injury;

Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.);

Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient;

Intracranial lesion.

External forces may include any of the following events: the head being struck by an object, the head striking an object, the brain undergoing an acceleration/deceleration movement without direct external trauma to the head, a foreign body penetrating the brain, forces generated from events such as a blast or explosion, or other force yet to be defined.

The above criteria define the event of a traumatic brain injury (TBI). Sequelae of TBI may resolve quickly, within minutes to hours after the neurological event, or they may persist longer. Some sequelae of TBI may be permanent.

Most signs and symptoms will manifest immediately following the event. However, other signs and symptoms may be delayed from days to months (e.g., subdural hematoma, seizures, hydrocephalus, spasticity, etc.).

Signs and symptoms may occur alone or in varying combinations and may result in a functional impairment. These signs and symptoms are not better explained by pre-existing conditions or other medical, neurological, or psychological causes except in cases of an exacerbation of a pre-existing condition. These generally fall into one or more of the three following categories:

Note: The signs and symptoms listed above are typical of each category but are not an exhaustive list of all possible signs and symptoms.

Comments on Part I of the common definition of TBI:

1. Regarding the requirements for clinical signs immediately following the traumatic event, note that only 1 of the 5 listed items is needed for the diagnosis.

Notably, there is NO requirement that there be loss or decreased level of consciousness at the time of the injury, although it is a common occurrence.

Any one of the 5 findings is sufficient for the diagnosis.

2. The definition also describes the mechanisms of injuries that may lead to TBI. TBI may therefore result from a motor vehicle accident, fall, blow to the head, penetrating brain wound, and other types of trauma, both in combat and not in combat, in addition to the blasts/explosions that have been a common source of TBI in veterans of the Afghanistan and Iraq conflicts.

3. The definition also mentions some of the possible delayed effects of TBI, including subdural hematoma, seizures, hydrocephalus, and spasticity. These will warrant service connection even if they don't appear for days, months, or possibly longer after the trauma, if attributable to an in-service TBI. A medical opinion will be needed in cases where the records do not indicate a clearcut etiology for a condition that is claimed as a delayed effect.

4. The definition also names the 3 categories of signs and symptoms that may be residuals of TBI, as discussed in previous training letters: physical, cognitive, and behavioral/emotional.

5. The definition also includes a discussion of the severity of TBI, as follows:

Part II of definition: Severity of Brain Injury Stratification

Not all individuals exposed to an external force will sustain a TBI. TBI varies in severity, traditionally described as mild, moderate and severe. These categories are based on measures of length of unconsciousness, post-traumatic amnesia.

The trauma may cause structural damage or may produce more subtle damage that manifests by altered brain function, without structural damage that can be detected by traditional imaging studies such as Magnetic Resonance Imaging or Computed Tomography scanning.

In addition to traditional imaging studies, other imaging techniques such as functional magnetic resonance imaging (fMRI), diffusion tensor imaging, positron emission tomography (PET) scanning, as well as electrophysiological testing such as electroencephalography may be used to detect damage to or physiological alteration of brain function.

In addition, altered brain function may be manifest by altered performance on neuropsychological or other standardized testing of function.

Acute injury severity is determined at the time of the injury, but this severity level, while having some prognostic value, does not necessarily reflect the patient’s ultimate level of functioning. It is recognized that serial assessments of the patient’s cognitive, emotional, behavioral and social functioning are required.

The patient is classified as mild/moderate/severe if he or she meets any of the criteria below within a particular severity level. If a patient meets criteria in more than one category of severity, the higher severity level is assigned.

If it is not clinically possible to determine the brain injury level of severity because of medical complications (e.g., medically induced coma), other severity markers are required to make a determination of the severity of the brain injury.

It is recognized that the symptoms associated with post traumatic stress disorder (PTSD) may overlap with symptoms of mild traumatic brain injury. Differential diagnosis of brain injury and PTSD is required for accurate diagnosis and treatment.

[NOTE TO VBN USERS: THIS IS A TABLE THAT I COULD NOT RE-CREATE. MIGHT NOT BE AS ACCURATE AS ORIGINAL SINCE I LISTED INSTEAD.]

Note: For purposes of injury stratification, the Glasgow Coma Scale is measured at or after 24 hours.

This stratification does not apply to penetrating brain injuries where the dura mater is breached.

Comments on Part II of the common definition (severity of brain injury stratification)

For rating purposes, these 3 points are most important.

Determination of the level of severity (mild, moderate, severe) is made at the time of the injury, that is, it is a determination of acute injury severity.

Once this acute level of severity is determined, it does not change, regardless of the veteran's course or extent of residuals.

Classification of the level of severity has no bearing on C&P evaluations.

As the definition says: " … this severity level, while having some prognostic value, does not necessarily reflect the patient’s ultimate level of functioning." This means that a veteran who was initially designated as having mild TBI may have severe residuals, and one who was designated as having severe TBI may have only mild residuals. Every individual recovers at his or her own rate and to an individual extent.

Therefore, the severity level assigned at the time of the acute trauma may or may not correspond to the severity of residuals that are the basis of the evaluation level you assign, and should not be a factor in determining the evaluation.

Note: The Glasgow Coma Scale, which is referenced in the table above as one of the criteria that may be used to determine the acute injury level, was included as part of previous training letter TL 07-05.

C. General Information About Rating Residuals of TBI

1. Categories of residuals. As the definition notes, the major residuals of TBI fall into three main categories: physical, cognitive, and behavioral/emotional. Examples of residuals that may be seen in each of these categories were provided in TL 07-05. Review the material in TL 07-05 and TL 06-03 for additional information about TBI.

2. Diagnostic codes for rating. Some of these residuals can be rated under the criteria in diagnostic code 8045; others will require evaluation under other diagnostic codes in the neurologic system, as well as under diagnostic codes in the mental disorders, eye, audio, and other body systems. TL 07-05 provides considerable information about evaluating physical residuals of TBI.

3. Levels of severity.

TL 07-05 referred to "mild TBI" and "post-concussion syndrome". However, because the acute severity determination has no effect on current evaluation, we have removed all references to mild, moderate, or severe from the regulation. You should ignore the discussions regarding these terms, as well as references to "post-concussion syndrome," that were discussed in TL 07-05 when evaluating TBI.

Therefore, the material in TL 07-05 under the section titled Evaluating Residuals of mild TBI (mTBI) no longer applies, nor does the material concerning assessment of cognitive function in the section titled "Evaluating residuals of moderate or severe TBI".

4. SMC: Revised diagnostic code 8045 points out the importance of considering the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc.

5. Combining under § 4.25/avoidance of pyramiding. Evaluate each residual condition separately, as long as the same signs and symptoms are not used to support more than one evaluation. Then combine the evaluations under § 4.25.

6. Prestabilization ratings. TL 07-05 addressed prestabilization ratings and this is another reminder to consider the possible benefits of an evaluation based on § 4.28 in a recently discharged veteran.

7. Associated injuries. Do not overlook the additional injuries that may also be present in a veteran with TBI – burns, shrapnel wounds, fractures, amputations, spine injuries, etc. These will require separate evaluations based on additional special examinations. For example, recently discharged veterans with severe burns will require a Scars examination, while those with facial injuries may require a Dental/oral examination as well as a Scars examination, Some veterans will need a Residuals of amputation examination or a Brain and Spinal Cord examination (when there is a spinal injury). Be sure to order all necessary special examinations, as indicated, rather than simply ordering a General Medical examination.

8. Future examinations. The TBI examination worksheet and template ask examiners whether the condition has stabilized, and if not, to provide an estimate of when stability may be expected. The information provided should guide the rater concerning the need for a future examination. If the examiner states that the condition has not stabilized, a future examination should be scheduled to take place soon after the estimated date of stability. A record of ongoing rehabilitation therapy would also be an indication that further improvement is possible and that a future examination should be scheduled. However, physical therapy and other treatments may be continued indefinitely to maintain functioning, even after stability has been reached. In most cases, stability is expected by 18-24 months after the date of injury. Therefore, scheduling a future examination after that date is often unwarranted, but should be determined for an individual veteran by the available information of record.

9. Delayed effects. See discussion above under definition.

D. Evaluating physical residuals of TBI

1. A list of some, but not all, physical residuals of TBI is included under diagnostic code 8045, as follows:

2. All physical residuals that are reported on an examination should be evaluated under the most appropriate diagnostic code and body system and combined under § 4.25.

3. These guidelines are basically unchanged from prior guidance.

E. Evaluating behavioral/emotional dysfunction in veterans with TBI

1. Behavioral/emotional symptoms are common in veterans with TBI and may arise from the effects of the TBI itself. However, comorbid mental disorders (especially depression, PTSD, and anxiety) are common in veterans with TBI and may also be the cause of behavioral/emotional problems. In some cases, TBI and one or more comorbid mental disorders both result in behavioral/emotional symptoms in the same veteran. The examiner has the task of determining the etiology of the symptoms that are present, and the rater has the task of determining how to evaluate them based on the examiner's determination of etiology.

2. Behavioral/emotional symptoms due to TBI fall most often under the neurobehavioral symptoms facet of the table in diagnostic code 8045, but at times (such as when mild anxiety is a major symptom) may also fall under the subjective symptoms facet.

3. Overlap of symptoms between comorbid mental disorders and residuals of TBI is common, and at times it is hard or impossible for an examiner to attribute the symptoms to one or the other. The examination protocol states: When a mental disorder is present, state, or ask the mental disorders examiner to state, to the extent possible, which emotional/behavioral signs and symptoms are part of a co-morbid mental disorder and which represent residuals of TBI. If it is impossible to make such a determination without speculation, so state.

4. The following table provides examples of situations that may be encountered in rating veterans with

[NOTE TO VBN USERS: THIS IS A TABLE THAT I COULD NOT RE-CREATE. MIGHT NOT BE AS ACCURATE AS ORIGINAL SINCE I LISTED INSTEAD.]

TBI when behavioral/emotional symptoms are present and offers guidelines on their evaluation.

NOTE: In this case, all behavioral/emotional symptoms are attributed to TBI, as there is no diagnosis of a mental disorder, and are evaluated under diagnostic code 8045.

Example: Veteran has TBI residuals that include mood swings, mild anxiety, and occasional troubling impulsive behavior. He does not meet the criteria for the diagnosis of a mental disorder. His behavioral/emotional symptoms result in moderate disruption of relationships with his family and friends. He does not work because of other TBI residuals that include severe migraine headaches, memory loss, and loss of concentration. His evaluation would be primarily under the table in diagnostic code 8045 for the neurobehavioral effects facet (at level 2). His mild anxiety alone would fall under the subjective symptoms facet (but only at level 0). His overall percentage evaluation under the table would depend on the severity of other problems he has, such as cognitive impairment, that could be assessed under this table, with the level of the facet with the highest level of severity being assigned.

NOTE: In this case, all behavioral/emotional symptoms are attributed to a mental disorder and are evaluated under § 4.130.

Example: Veteran has numerous physical residuals of TBI. He also has classical symptoms of PTSD and meets the criteria for a diagnosis of PTSD associated with the trauma (nearby grenade explosion) that led to his TBI. The examiner states that his behavioral/emotional symptoms can all be attributed to his comorbid PTSD rather than to the TBI itself.

NOTE: In this case, all behavioral/emotional symptoms are attributed to TBI and are evaluated under the table in diagnostic code 8045. While there is a diagnosis of a mental disorder, no current symptoms are attributed to it.

Example: Veteran suffered a TBI due to a roadside bomb in Iraq. He has minor physical symptoms but is more troubled by symptoms of depression, apathy, and verbal aggression that occasionally interfere with workplace and social interaction. He has a diagnosis of mild obsessive compulsive disorder, but it is currently in remission. His symptoms would be evaluated as part of his TBI under the neurobehavioral effects facet (at level 1).

NOTE: In this case, the examiner has distinguished which symptoms arise from TBI and which arise from a mental disorder. Therefore, 2 separate evaluations are needed.

Example: Veteran was struck by falling debris after an explosion damaged a building when he was on patrol. He has loss of concentration and attention and is confused and fearful when trying to follow directions, getting lost on a daily basis in the community, although never at home. He is also very tense and anxious, and at times is belligerent and uncooperative. Another major problem is a lack of self-awareness of the severity of his disability. The examiner diagnosed both a generalized anxiety disorder (manifested by tenseness and anxiety) and neurobehavioral residuals of TBI (lack of self-awareness, belligerence, and lack of cooperation). Two separate evaluations are needed, one for anxiety disorder under § 4.130 and one for neurobehavioral effects under diagnostic code 8045. The level of severity of the neurobehavioral effects facet may be less than the level of severity of other facets that require evaluation under the table in diagnostic code 8045 (such as the cognitive impairment and impaired visual spatial orientation facets). The percentage evaluation would be based on the level of the facet with the highest level of severity.

Situations #5

Conditions(s) diagnosed: TBI
Behavioral/emotional symptoms attributed to: Unable to determine
Evaluate under: Evaluate under either General Rating Formula for Mental Disorders in § 4.130 or under Table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified."

Conditions(s) diagnosed: Mental disorder
Behavioral/emotional symptoms attributed to: Unable to determine
Evaluate under: Evaluate under either General Rating Formula for Mental Disorders in § 4.130 or under Table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified."

NOTE: In this case, the examiner has been unable to distinguish the source of symptoms. Evaluation is made under whichever set of evaluation criteria allows the better assessment of overall impaired functioning due to behavioral/emotional symptoms of both conditions.

Example: Veteran has numerous behavioral/emotional symptoms (depression that severely affects his work and his family relationships, frequent suicidal thoughts, confusion, apathy, and unpredictability) and meets the diagnostic criteria for TBI and for major depression, after 3 combat tours in Iraq during which he suffered at least 4 TBI's. Since the examiner was unable to sort which symptoms are associated with TBI and which with major depression, an evaluation under either the General Rating Formula for Mental Disorders in § 4.130 or under the table in diagnostic code 8045 could be made, depending on which better assesses overall functional impairment. In this case, the depressive symptoms are severe and prominent, affecting all aspects of this veteran's life, and, in combination with the symptoms of confusion, apathy, and unpredictability, are totally disabling. A 100% evaluation under the General Rating Formula for Mental Disorders would better represent the overall extent of his severely impaired functioning because the table in diagnostic code 8045 does not allow an evaluation of "total" under the neurobehavioral effects facet.

F. Table for “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified”

1. Introduction

a. 10 facets: The table includes 10 facets of dysfunction that may be seen after TBI, in addition to the types of physical dysfunction and the comorbid mental disorders that may be present and are evaluated elsewhere. The facets are: memory, attention, concentration, executive functions; judgment; social interaction; orientation; motor activity (with intact motor and sensory system); visual spatial orientation; subjective symptoms; neurobehavioral effects; communication; and consciousness.

b. Levels of facets: The potential levels that may be assigned for each facet based on the severity of findings are 0, 1, 2, 3, or "total". However, not every facet has all 5 potential choices of severity. For example, the consciousness facet has only a single level, "total," since any level of impaired consciousness would be totally disabling.

c. Evaluation level under the table: Once the level of severity of each facet has been determined, if one or more facets is deemed to be at the level of "total," assign a 100% evaluation. If no facet meets the criteria for "total," base the overall percentage evaluation on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet.

d. Note: The evaluation assigned based on this table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations.

e. Examples in facets: When specific examples of symptoms are listed under a facet, remember that these are only examples, and there is no requirement that any of the listed examples be present in order to assign a particular evaluation level.

2. The memory, attention, concentration, executive functions facet.

a. Evaluation levels:

This facet has levels of 0 through "total" that are based on the extent of loss of memory, concentration, attention, or executive functions and their effect on functional impairment.

Levels 2, 3, and "total" require that there be objective evidence on testing of impairment of memory, concentration, attention, or executive functions. In many cases, such evidence may be of record based on neuropsychological testing done previously. If not, testing will be required. There are an array of available neuropsychological tests, and the specialist conducting the examination can best determine what tests, if any, are needed in a particular case.

Level 1 may be assigned based solely on a complaint of mild loss of memory, etc., without objective evidence on testing, and level 0 means there are no complaints in these areas.

b. Impairment of only one element is needed:

Note that this facet requires only that either memory, attention, concentration, or executive functions be impaired, for a 1, 2, 3, or "total" evaluation level, so that all but one of these elements may be normal and any of these 4 levels may still be assigned as long as one of the elements meets the criteria.

3. Subjective symptoms due to TBI.

a. General information about subjective symptoms:

Subjective symptoms such as headache, dizziness, fatigue, and sleep disturbances are common after TBI and may be its only residuals. However, they may also be associated with, or part of, cognitive impairment or other areas of dysfunction. As discussed above, subjective symptoms may also be associated with a comorbid mental disorder.

b. Subjective symptoms under former diagnostic code 8045:

Former diagnostic code 8045 stated that purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304, that this 10 percent rating will not be combined with any other rating for a disability due to brain trauma, and that ratings in excess of 10 percent for brain disease due to trauma under diagnostic code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma.

Diagnostic code 9304 is "dementia due to head trauma". Multi-infarct dementia is now referred to in DSM-IV as "vascular dementia" and is the title of diagnostic code 9305. All of these rules concerning subjective symptoms evaluation have been removed.

c. New evaluation of subjective symptoms:

Under the new regulation, both cognitive impairment and subjective symptoms that are residuals of TBI, are evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified”. The subjective symptoms need not be part of or associated with cognitive impairment to be evaluated under this table.

There is no longer a prohibition on assigning more than 10 percent for subjective symptoms. A level of 0, 10, or 40% may be assigned under the table based solely on subjective symptoms.

There is also no longer a prohibition on assigning an evaluation for subjective symptoms in addition to assigning one or more evaluations for other residuals of TBI. However, in many cases, subjective symptoms will be the only residuals of TBI.

The lowest level, 0, which equates to 0%, is assigned if there are subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships.

Examples for this level are mild or occasional headaches and mild anxiety.

The highest level, 2, is assigned if there are three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days.

d. Distinct conditions with subjective symptoms:

Separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.”

If only some of the subjective symptoms can be evaluated under other diagnostic codes, the remaining symptoms may be evaluated under the "Subjective symptoms" facet, as long as the criteria are met.

e. IADLs:

The term "Instrumental Activities of Daily Living" (IADLs) is used in the criteria for this facet. IADLs refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone.

These activities are distinguished from "Activities of daily living," which refer to basic self-care and include bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet.

4. Neurobehavioral effects of TBI

a. This facet refers to behavioral changes resulting from TBI. The types of effects and their severity depend on the location (frontal lobes, temporal lobes, diffuse brain injury, etc.) and extent of the injury.

b. The facet lists the following examples of neurobehavioral effects: irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. These are among the more common neurobehavioral effects but are not the only ones possible.

c. Any of the effects has a potential range of slight to severe. Therefore, it is not necessarily the type of effect that is present but the resulting impact on workplace interaction, social interaction, or both, that determines the level of evaluation. However, in general, verbal and physical aggression are likely to have a more serious impact on interaction than some of the other effects.

d. The level of evaluation for neurobehavioral effects range from 0 through 3, based on the extent of interference with workplace interaction, social interaction, or both.

5. Overlapping manifestations of facets in table and manifestations of a mental or neurologic or other physical disorder.

The manifestations of conditions evaluated under the “Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified” facet may overlap with those due to a comorbid mental disorder or with those of a neurologic or other physical disorder that can be separately evaluated under another diagnostic code.

In such cases, as always, based on § 4.14, do not assign more than one evaluation based on the same manifestations.

If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions.

However, if the manifestations are clearly separable, assign a separate evaluation for each condition.

6. Determining the facets levels.

The examination protocols include the criteria for the various levels of severity of each facet, and the examiner will be asked to select the appropriate choice. Therefore, the rater will generally not need to make these determinations of severity but will need to review all the available pertinent material to make sure the examiners' responses are consistent with other information.

G. Types of examinations and examiners.

1. Health care providers who may conduct TBI examinations.

The change in the way cognitive impairment is assessed under the new regulations requires that the list of qualified examiners to conduct examinations for TBI be much more limited than the list of those who could conduct TBI examinations under the former regulations.

Formerly, cognitive impairment could only be assessed under the General Rating Formula for Mental Disorders, so a special mental disorder examination was required whenever cognitive impairment was at issue. A general medical examiner could conduct other parts of the TBI examination. Under the newregulations, cognitive impairment is evaluated under diagnostic code 8045 rather than under § 4.130, and the primary examiner must assess cognitive impairment as well as other TBI residuals as part of the TBI examination. The examiner must also be able to assess whether stability has been reached, and if not, when it is likely. This requires an examiner with training, experience, and expertise in TBI, and one who has the capability of assessing cognitive impairment, neurobehavioral problems, visual spatial problems, etc.

Veterans Health Administration TBI experts have determined that the following examiners qualify to conduct TBI examinations: Physicians who are specialists in Physiatry, Neurology, Neurosurgery, and Psychiatry and who have training and experience with Traumatic Brain Injury may conduct TBI examinations. The expectation is that the physician would have demonstrated expertise, regardless of specialty, through baseline training (residency) and/or subsequent training and demonstrated experience.

In addition, a nurse practitioner, a clinical nurse specialist, or a physician assistant, if they are clinically privileged to perform activities required for C&P TBI examinations, and have evidence of expertise through training and demonstrated experience, may conduct TBI examinations under close supervision of a board-certified or board-eligible physiatrist, neurologist, or psychiatrist. These examinations would require a second signature by one of the qualified specialists listed above.

There is no longer a need for a mental disorder examination whenever cognitive impairment is at issue. Any of the qualified examiners, including psychiatrists, may conduct the entire TBI examination. When a non-psychiatrist conducts the examination, a mental disorder examination by a specialist will still be needed if a mental disorder is at issue. Additional special examinations, such as those for hearing and vision, will also still be needed when indicated.

2. Tests that may be needed

X-rays in the case of a skull defect.

Neuropsychological testing when indicated. Some or all of the Halstead-Reitan Neuropsychological Battery, for example, is often used. But there are numerous tests that may be used, depending on particular needs and preferences. See http://www.brainsource.com/nptests.htm for a list of over 60 specific tests that may be used and their purposes.

Other special tests may be called for, depending on the particular residuals.

H. Rating review under new diagnostic code 8045

1. Re-review. Note 6 in new diagnostic code 8045 provides that a veteran whose residuals of TBI were rated under a prior version of diagnostic code 8045 may request review under the new criteria. This differs from a regular claim for increase in that there is no requirement that there be an indication that the disability has worsened. This review will allow veterans to be re-rated with new examinations that conform to the new criteria to ensure an adequate rating is provided.

2. Effective Date. The effective date of any increase in disability rating will be based on the regulations for effective dates for increased ratings, § 3.400(o), etc. However, the effective date of any award or any increase in disability compensation, based solely on the new rating criteria, will not be earlier than the effective date of the new criteria.

3. Reduction. Under § 3.951, any review under the new criteria will not result in a reduction in a veteran’s disability rating, unless the veteran’s disability has been shown to have improved. A rating may be reduced under § 3.105 if the veteran has shown improvement since the last review.

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I have kept all information in this manual. The Table of Contents page numbers are not valid for this version since I have eliminated all of them. They interfered in the actual information for this version. I have also altered some paragraphs to make them easier to read. Some tables have also been remade since I could not make the actual tables. If you are wishing to quote, be aware. You might want to find the link and quote direct from the document. If the link disappears, this will, hopefully, still be here.

This document provides information on Posttraumatic Stress Disorder and current recommendations regarding what is known about “best practice” procedures for assessing PTSD among veteran populations. A Veterans Benefits Administration (VBA) review of 143 initial claims for PTSD revealed that PTSD was diagnosed in 77% of the cases, that the exam was not adequate for rating in at least 8%, but that inadequate exams were not routinely returned for correction. A common problem was that the examiner did not describe how Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) diagnostic criteria were met. Good exams delineated how the PTSD diagnostic criteria were met by giving specific examples. Other noted problems were the examiner using DSM-III rather than DSM-IV criteria, and the examiner sometimes failing to discuss whether other mental disorders that were diagnosed are due to or part of PTSD. The VBA and Veterans Health Administration (VHA) are committed to improving these services to veterans, and improving the quality of compensation and pension examinations for PTSD.

Included in this manual are an assessment protocol based on best practices for assessing PTSD, and disability examination worksheets which correlate with the protocol. Included in the protocol are guidelines on:

The VHA encourages use of this protocol when examining veterans for compensation purposes to ensure that a detailed history is obtained from the veteran and a comprehensive evaluation is performed and documented.

Comprehensive report templates have also been included as guides when writing reports.

Also included in this manual as reference material are:

• The VBA training letter based on a PTSD case review

• The governing regulation from 38 CFR, Part 3 for Service Connection for PTSD

• Background research on PTSD and the Global Assessment of Functioning (GAF)

• The GAF Scale

• Scoring rules for Mississippi and PTSD checklist

• Examples of trauma history and PTSD symptom narratives

• A social history questionnaire.

It is anticipated that this document will raise the quality and standards of PTSD Compensation and Pension (C&P) examinations. This increased quality will require increased time and expense allotted to the evaluation process. Under current VA standards, with local and regional variations in time mandated for exams, clinical expertise, and resources, the examiners must use their discretion in selecting the most relevant information for completing a competent, comprehensive examination for PTSD.

A review of 143 initial claims for PTSD under a special protocol was conducted during the week of June 19, 2000, by three field reviewers and one member of the Star Review Staff under the supervision of Dr. Caroll McBrine. The statistics reported are based on the 143 files formally reviewed, but an additional 77 cases were informally reviewed. The review was not statistically valid but was sufficient to point out problem areas that call for additional training.

Examination findings

• PTSD was diagnosed in 77% (75/97 exams).

• The exam was not adequate for rating in at least 8% (, but only 3 were returned.

• The examiner reconciled multiple psychiatric diagnoses in all but 3 or 35% (34) where they were present.”

• The examiner had the claims folder in 44% (43).

• The examiner considered and discussed documentary evidence in 36% (35).

• The examiner identified the stressor and commented on the nexus in 68% (51/75).

• A common problem (in at least 5 exams) was that the examiner did not describe how DSM-IV diagnostic criteria were met. All exams were accepted by regional office (RO), but should have been returned. Good exams delineated how the PTSD diagnostic criteria were met by giving specific examples.

• The examiner clearly used DSM-III rather than DSM-IV criteria in many cases.

• The examiner sometimes failed to discuss whether other mental disorders that were diagnosed are due to or part of PTSD.

PTSD is a prevalent mental disorder among veterans exposed to traumatic stress during military service. The VA’s commitment to providing thorough and accurate assessment and care of veterans raises a need for a more standardized approach to assessment and documentation of PTSD and resulting impairment in psychosocial functioning. This background information reports on the current standards for PTSD assessment. Further information on the research associated with PTSD is included in Appendix E.

Assessment of PTSD

PTSD is assessed by a variety of methods, including questionnaires, interviews, and biological tests. Chapter 2 gives a summary of the recommended instruments and format for PTSD assessment. Under optimal circumstances, assessment of PTSD and associated disorders is based on multiple sources of information, derived from clinical interview, psychometric testing, review of military and medical records, reports from collaterals who know the veteran, and studies of psychophysiological reactivity. A multi-method approach is especially helpful to address concerns about either denying or overreporting symptoms.

Many clinicians find the addition of the Minnesota Multiphasic Personality Inventory (MMPI) and Minnesota Multiphasic Personality Inventory-2 (MMPI- 2 helpful, particularly in very complex or difficult cases. The MMPI and MMPI- 2 include scales that assess overreporting; they have what are known as “validity scales” that are elevated in people who are trying to exaggerate their symptoms. There has been evidence to suggest that compensation-seeking veterans endorse higher levels of psychopathology across measures and produce elevated validity indices on the MMPI and MMPI-2 as compared to non-compensation-seeking veterans (Smith & Frueh, 1996; Frueh & Kinder, 1994). Sample sizes in these studies, however, are small, and clinicians were not correlating scores on the MMPI with collateral sources of data suggestive of overreporting. Even in non-compensation-seeking settings, the preponderance of evidence suggests that people with PTSD report significantly higher subjective distress than those without PTSD. Several studies suggest that Vietnam combat veterans and child abuse survivors may have elevated scores as a result of chronic post traumatic difficulties or comorbid affective symptoms, as opposed to motivated symptom overendorsement (Elliott, 1993; Jordan, Nunley, & Cook, 1992; Smith & Frueh, 1996).

The Infrequency-Psychopathology Scale F(p), was designed by Arbisi and Ben- Porath (1995), for the MMPI-2 as an additional validity measure for use with patient populations where a high rate of endorsement of psychological disturbance is expected. The scale’s validity has been tested in with inpatient veterans, with results indicating that the F(p) scale may be used as an adjunct to the F in settings characterized by relatively high base rates of psychopathology and psychological distress. Arbisi and Ben-Porath suggest that when the F(p) scale is elevated along with the F Scale, the clinician can more confidently attribute the high scores to a patient’s attempt to overreport psychopathology if other validity measures are not elevated significantly. The F(p) Scale is less influenced by diagnostic group and distress/psychopathology than the F Scale in distinguishing groups with genuine psychopathology from those asked to feign psychiatric impairment (Arbisi and Ben-Porath, 1997; 1998). In patients likely to be encountered in both clinical and forensic settings, elevations on the F(p) Scale are much more common when malingering or exaggeration of psychopathology is expected (Rothke et. al, 2000). Hit rates (Rothke et. al. 2000) and cutoff scores (Strong et. al., 2000) have been reported across a number of settings (see disability examination worksheets for cutoff scores). Nonetheless, it is critical that clinicians understand the nature of their population with regard to frequency and type of psychopathology before interpreting the F(p) Scale. Independent verification that patients are overreporting is needed. With this caveat in mind, use of the MMPI and MMPI-2 may help the evaluator in determining test-taking style of the veteran (i.e., defensive, overendorsing, underendorsing).

In using the MMPI-2 to assess for PTSD, cutoff scores for utilizing the MMPI-2 to assess validity of PTSD diagnosis have been reported in a number of studies (Lyons, 1999; Wetter et al., 1993). In addition, MMPI-2 cutoff scores for specific PTSD scales (i.e., PK, PS) have been shown to be effective at assessing PTSD (Lyons & Keane, 1992). (See disability examination worksheets for cutoff scores). A Cochrane review of Effectiveness report (September, 2000) indicated that six of 21 studies reviewed (29%) reported that the mean 8-2 profile pattern significantly differentiated PTSD from non-PTSD patients. Seven (33%) of the studies demonstrated either no significant mean two-point profile pattern differences, or differences that were attributable to scale elevations, but not mean code type patterns. In five of these seven studies, mean 8-2 profile patterns were produced by both the PTSD and comparison samples, although the PTSD groups were significantly more elevated than the comparison groups. Of seven inpatient veteran studies, all reported an 8-2 mean profile pattern, although four of these reported non-significant differences. When five outpatient veteran studies were grouped together, 50% demonstrated the mean 8-2 profile pattern. The three POW studies were consistent in generating an averaged 1-2 profile pattern. Of the eight studies that reported many profile patterns other than the 8-2, the most frequent mean two-point profile patterns were 1-2 (four, 19%), 4-8 (three, 14%), 4-2 (three, 14%), and 8-7 (three, 14%).

At this time, the current findings call for careful and accurate, multimodal assessment, and a conservative approach in our ability to interpret symptom overendorsement in the context of psychometric testing alone. Comprehensive assessments based on multiple sources of information that yield consistent results tend to create greater confidence in the veracity of diagnostic judgments.

Biological measures such as measures of heart rate, blood pressure, skin conductance, and EKG muscle tension have been found to yield valuable information for corroborating a PTSD diagnosis (Keane et. al, 1998). Veterans more prone to psychophysiological response to war-zone cues tended to be more impaired on both clinician and self-report measures of PTSD, have poorer functioning, and endorse patterns of guilt and depression. However, it is important to keep in mind that some psychophysiological responses can be fabricated, and almost one third of veterans with PTSD do not show a psychophysiological response to war-zone cues. Therefore, biological data can best be framed as corroborative of other data, rather than as a determining factor in making a diagnosis.

Assessment of Functioning Using the GAF Scale

In 1997, the Department of Veterans Affairs mandated (VHA Directive # 97- 059) that a GAF score be assigned at regular intervals for veterans receiving mental health care in the VHA system. According to this directive, the GAF scores were to be used to define who is seriously mentally ill (SMI), and to calculate a GAF index for the SMI population in 1998.

On occasion, the GAF score has been employed by disability rating boards as an index of a claimant’s functional status as part of the process of determining eligibility for benefits. The GAF scale was included as the fifth axis in a DSM profile beginning as a 7-point format with the DSM-III. It was changed from a 7-point scale in DSM-III to a 0-90 point scale in DSM-III-R, and to a 0-100 point scale in DSM-IV. The current version of the GAF is based on the Global Assessment Scale (GAS) developed by Endicott and colleagues. The GAF and the GAS are almost identical to each other in content, with the exception of some re-arrangement of rating descriptions and examples for the categories. While no information on the reliability and validity of the GAF is included in the DSM-IV, these psychometric features of the GAS were formally examined and published by the GAS authors (Enidcott, Spitzer, Fleiss & Cohen, 1976; see Appendix F of this manual for more details on the GAS).

GAF Rating Issues

1. GAF Reliability and Training.

The existing GAF literature shows that in the absence of systematic training with the GAF, reliability is generally poor. Evidence suggests that without training some raters may base their ratings on average symptom occurrence or functionality over time, while others will rate the most recent episode or lowest level of these two components. In disorders like PTSD, where symptom severity and functionality can fluctuate, these two approaches will yield very different GAF scores. Therefore, training in using the GAF with PTSD is essential.

2. GAF Accuracy and Clinician-Rater Biases.

While training is important for obtaining reliable ratings; high accuracy should be given equal consideration. Outcome data from GAF trainings have shown that raters show a bias against assigning low GAF scores for PTSD vignettes. For PTSD cases used as part of organized GAF trainings, it was typically true that the GAF ratings made before training were too high. This reflected various biases and beliefs of the clinician raters regarding what defined a functional problem, and equally important, their personal perspective on what qualified as a “mild,” “moderate,” and “serious” levels of severity. These biases affect the accuracy of the GAF rating assigned.

3. GAF Accuracy with PTSD and Comorbidity.

DSM-IV GAF symptom examples in the text do not represent PTSD symptoms directly, although they capture associate features and general level of functioning . The clinician must decide what should be considered as either a symptom or functional problem that is then rated for its severity (e.g., avoidance can be an individual PTSD symptom and part of more broad social and interpersonal dysfunction). Additionally, the presence of other comorbid diagnoses is common in cases of chronic PTSD. To assess PTSD symptom severity in the context of comorbidity, the clinician must somehow weigh the combined impact of all coexisting diagnoses, but without directions or examples.

4. Resolution of the GAF Scale.

The GAF scale is organized into 10 decile (10- point) bands that yield 100 possible points. Available GAF instructions recommend first finding the decile band that seems to best describe either the degree of symptomatology or functional severity. Then, parenthetically, the DSM-IV adds a note advising that the rater “use intermediate codes when appropriate ( e.g., 45, 68, 72)”, but gives no guidance on exactly how to arrive at these intermediate values. Practically speaking, the larger deciles may have greater reliability because they are more clearly specified in the DSM-IV and thus easier to select. Consequently, if GAFs are based only on decile values (30, 40, 50, 60, etc.), then the difference between raters assigning GAFs for the same patient could easily vary by 20 points. This could occur, for example, if one rater considered the symptoms to be Mild and the other judged them to be Moderate - Severe in nature. This discussion highlights the problem of using GAF cutoff scores that set strict thresholds for disability (e.g., 40 and higher is not disabled / below 40 is disabled). This is unwise and unsupported by both the inherent resolution of the GAF scale (3 – 5 points) and the data from standardization studies of the GAS (see Appendix F) showing that raters normally vary by as much as 5 to 8 points.

5. Assigning Separate GAFs by Condition.

No published information associated with the DSM-IV instructs users in a valid method for partitioning the GAF score (Partial Assessmemt of Functioning [PAF]) by comorbid clinical conditions for the areas of Social and Occupational / School functioning. While the same is also true for Psychological functioning, it might appear from reading the descriptors in DSM-IV (i.e., mild, moderate, serious) that separate ratings by diagnosis could be made (e.g., only for depression symptoms, only for anxiety symptoms, only for substance abuse symptoms). However, the separate ratings that would result have no validated relationship to each other, and no established process for integrating them into a value that truly considers the combined effect of having them all concurrently. Second, if PAFs are requested for a disability determination, it is likely that multiple conditions exist comorbidly, and having separate ratings of severity of dysfunction would fit with a process of assigning a percentage of service connection to each particular disorder. In PTSD, depression and substance abuse frequently coexist and attempting to attribute a portion of the functional problems to depression and another to substance use and another to PTSD, as if they were independent of each other, is beyond the intended purpose and capability of the GAF scale. This is an instance of incompatibility between the capabilities of the GAF scale and the compensation review process. While the logic of separate ratings by disorder may make sense from an adjudication perspective, it is not clinically validated, and PAFs assigned in this manner should be seriously questioned for their validity as evidence in the disability determination proceedings.

Some Considerations for Making GAF Ratings:

Given the GAF considerations described above, clinicians who assign GAF ratings should: a) attend available trainings, b) study available GAF materials carefully, c) try to assign scores as accurately as possible by adhering to the definitions provided, and d) strive to become consistent in choosing their GAF ratings.

It is important to gather through multiple means (i.e., structured interview, social history, self-report measures), an assessment of the individual’s level of functioning across the time periods prior to, during, and subsequent to military service. Areas of functioning to assess include: developmental, social, familial, educational, vocational, cognitive, interpersonal, behavioral, and emotional domains. The clinician is then responsible for assigning a GAF score, but more importantly including sufficient narrative which supports the rationale behind the score assigned.

At the current time, existing Disability Examination worksheets (as included in this publication) reflect VBA’s policy of sometimes requesting that the examiner partition out GAF scores for comorbid disorders. While this information may be requested, if the clinician feels that to do so would be impossible or clinically invalid, he or she is not required to do so, and should state specifically why he or she feels that this is not possible.

Finally, in making ratings, clinicians should be cognizant of the presence of violence toward self and others in the veteran’s history. While these events may be episodes of aggression vs. continuous aggression or a general aggressive demeanor, they are significant features that drop the GAF into the lower decile ranges. If these features are present clinically, they should not be overlooked or minimized by the clinician when making GAF ratings, even if it appears that the veteran has higher functionality in other areas.

III. Recommended Guidelines for Assessing Trauma Exposure and PTSD

A. Trauma Exposure Assessment

A.1. Objective.

Compensation and pension examinations routinely address PTSD resulting from combat exposure. However, many other forms of military-related stress are sufficient to induce PTSD and should be reviewed among veterans applying for service-connected disability benefits. Non-combat forms of military-related trauma that are not uncommon include sexual assault or severe harassment; non-sexual physical assault; duties involved in graves registration or morgue assignment; accidents involving injury, death, or near death experiences; and actions associated with peace-keeping deployments that meet the DSM-IV stressor criterion.

The objective of trauma assessment is to document whether the veteran was exposed to a traumatic event, during military service, of sufficient magnitude to meet the DSM-IV stressor criterion, described below.

DSM-IV Stressor Criterion

The person has been exposed to a traumatic event in which both of the following have been present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;

Note. Adverse psychological reactions are often associated with stressful events that have the quality of being unpredictable and uncontrollable. Additionally, stressors that result in bodily injury, threat to life, tragic loss of a significant other, or involvement with brutality or the grotesque heighten risk for subsequent PTSD. Exposure to assaultive violence, particularly of a criminal nature, is more likely to induce PTSD than are random “acts of God.” It is known that severity of the stressor, in terms of intensity, frequency, and duration, is the most important trauma characteristic associated with subsequent development of PTSD. Factors surrounding the trauma incident, such as absence of social support for the victim, may also influence the degree to which a stressful event is experienced as psychologically traumatic and may contribute to its potential for inducing psychiatric symptoms.

A.2. Sources of information used in trauma assessment.

Multiple sources of information should be used to assess history of exposure to traumatic stress, as well as its nature and severity. These sources include:

(d) statements from others who have information about the veteran’s trauma exposure and its behavioral sequela,

(e) evidence of behavior changes that occurred shortly after the trauma incident, and

(f) statements derived from interview of the claimant.

The occurrence of some forms of trauma (e.g., combat exposure) are usually substantiated by official military records, while support for other stressors (e.g., sexual assault) may depend on sources other than military records. (See Section VII for further information about supporting evidence regarding traumatic stressors.)

A.3. Guidelines for interview assessment of trauma exposure.

Initial examinations conducted for purposes of establishing a diagnosis of PTSD require clinician assessment of trauma exposure and documentation of findings. Provided below are guidelines for (a) orienting the claimant to the interview assessment process, (b) gathering and documenting information about the trauma, (c) eliciting information about the stressor from the claimant, and (d) assessing trauma using structured questionnaire and interview methods.

A.3.a. Orienting the claimant to trauma assessment.

For initial examinations, it is important to explain to the claimant that it is necessary to obtain a detailed description of one or more traumatic events related to military service, in order to complete the examination. Further, it is helpful to alert him or her to the fact that trauma assessment, though brief (about 15-20 minutes), may cause some distress. The veteran should be advised that trauma assessment is a mutual and collaborative process, and that he or she is not required to provide unnecessarily detailed answers to all questions, if it is too distressing to do so.

A.3.b. Documentation of trauma-related information.

For initial examinations, a detailed narrative description of the traumatic episode must be recorded in the report. This description, as appropriate and feasible, should include information about:

(1) the objective features of the traumatic event;

(2) date and location of the stressor(s);

(3) names of individuals who witnessed or were involved in the traumatic incident;

(4) individual decorations or medals received;

(5) the veteran’s subjective emotional reaction and behavioral response during and after the trauma;

(6) the veteran’s view of perceived consequences of the traumatic event, including abrupt changes in behavior, adjustment, and well-being; and

Assessment of one or more personally relevant traumas proceeds after sufficient rapport has developed and some cursory details regarding the context of the trauma situation(s) have been gathered (e.g., branch of the military served in; events leading up to the traumatic situation). Provided below are suggested questions, strategies, and tools that mayassist in trauma assessment, as appropriate to the nature and context of the veteran’s stressful military experiences:

Stem or lead inquiry:

The Clinician Administered PTSD Scale (CAPS) (Blake et al., 1995) strategy for assessing the stressor criterion is recommended for the initial inquiry about trauma exposure. This strategy involves the following orienting procedures and questions:

Orienting statement:

“I’m going to be asking you about some difficult or stressful things that sometimes happen to people. Some examples of this are being in some type of serious accident; being in a fire, a hurricane, or an earthquake; being mugged or beaten up or attacked with a weapon; or being intensely sexually harassed or forced to have sex when you didn’t want to. I’ll start by asking you to look over a list of experiences like this and check any that apply to you. Then, if any of them do apply to you, I’ll ask you to briefly describe what happened and how you felt at the time.

“Some of these experiences may be hard to remember or may bring back uncomfortable memories or feelings. People often find that talking about them can be helpful, but it’s up to you to decide how much you want to tell me. As we go along, if you find yourself becoming upset, let me know and we can slow down and talk about it. Do you have any questions before we start?”

Administration of the CAPS Life Event Checklist:

The CAPS 17-item Life Event Checklist may be administered as a preliminary means of identifying exposure to different traumatic events. Detailed inquiry should follow positive endorsement of traumatic events, in order to clarify objective features of the stressor, using questions suggested below as appropriate:

• Were you wounded or injured?

• Did you witness others being killed, injured or wounded?

• Were you exposed to bodies that had been dismembered?

• About how many times were you exposed to [the traumatic event]?

• During the trauma, did the perpetrator coerce (i.e., threaten, demand, push, trick) you into doing something against your will? (sexual assault)

• During the trauma, did the perpetrator threaten to injure you or kill you if you did not comply with his or her wishes? Did you believe there would be any other negative consequences to you if you did not comply with the perpetrator’s intentions (i.e., do what was demanded)? (sexual assault)

• Was somebody important to you killed or seriously hurt during this situation?

• What did other people notice about your emotional response?

• What were the consequences or outcomes of this event?

• Did you receive any help, or talk to anyone, after this event occurred?

Suggested Questions for Screening Sexual Assault Experiences:

“Have you ever had any unwanted or uncomfortable sexual experiences, either as a child or an adult?”

The Life Events Checklist has 2 questions that offer the opportunity for the assessor to ask follow-up questions. It is suggested that you change the listed follow-up questions referring to sexual assault experiences to questions such as:

a) During this event, did the other person pressure you verbally or physically to do something against your will?

b) During this event, did the other person threaten to hurt or kill you if you didn’t do what he or she wanted?

c) Did you think that there would be something else that would happen if you didn’t do what he or she wanted?

a) At the time the trauma was occurring, did you believe your life was threatened? Did you think you could be physically injured in this situation?

b) At the time this occurred, how did you feel emotionally (fearful, horrified, helpless)?

c) Were you stunned or in shock so that you didn’t feel anything at all?

d) Did you disconnect from the situation, like feeling that things weren’t real or feeling like you were in a daze?

e) Can you recall any bodily sensations you may have had at the time?

Suggested inquiries if no events are endorsed on the CAPS trauma exposure checklist:

If no events were identified on the CAPS trauma exposure checklist or during other parts of the interview, consider the following additional inquiries:

a) Has there ever been a time in the military when your life was in danger or you were seriously injured or harmed?

b) What about a time when you were threatened with death or serious injury, even if you weren’t actually injured or harmed?

c) What about witnessing something like this happen to someone else or finding out that it happened to someone close to you?

d) What would you say are some of the most stressful experiences you had during the military, which still upset you today?

A.3.d. Recommended Instruments for Trauma Assessment.

The following instruments are useful in assessing objective features of trauma exposure. These instruments should be administered only to claimants who represent the appropriate criterion group that the instruments were developed for. Clinicians may use items from these instruments as prompts for interview questions, and responses to items may provide a focus for more detailed interview inquiry. Some instruments (e.g., the Combat Exposure Scale) provide sufficient information to make gross assessments of whether the individual was exposed to a “high,” “moderate,” or “low” degree of trauma. While helpful, use of these instruments is never sufficient, and must be accompanied by a narrative description of unique details of the veteran’s traumatic experience. Many of the self-report measures noted in this document have means and cut-off scores that were validated on combat veterans. Other traumatized populations (i.e., sexual assault) may look differently on these measures.

Infantryman and other ground troop personnel

• Combat Exposure Scale (Keane et al., 1989)

Females serving in a war zone

• Women’s Wartime Stressor Scale (Wolfe, Brown, Furey, & Levin, 1993)

• Trauma Questionnaire (McIntyre et al., 1999).

Persian Gulf War Veterans

• Desert Storm Trauma Exposure Questionnaire (Southwick et al., 1993)

Veterans Exposed to Sexual Assault (both male and female)

• Sexual Experiences Survey (SES, Koss & Oros, 1982).

Veterans Exposed to Sexual Harassment (both male and female)

• Sexual Experiences Questionnaire (SEQ-DOD, Fitzgerald, Gelfand, & Drasgow, 1995). There is a version specifically asking about sexual harassment in the military.

B. Assessment of PTSD

B.1. Objective.

Assessment of PTSD for compensation and pension purposes should address four objectives:

(a) establish the presence or absence of a diagnosis of PTSD;

(b) determine the severity of PTSD symptoms;

(c) establish a logical relationship between exposure to military stressors and current PTSD symptomatology; and

(d) describe how PTSD symptoms impair social and occupational functioning and quality of life.

Assessment of PTSD requires inquiry into the presence/absence of all 17 symptoms of the disorder, but consideration should also be given to associated features articulated in DSM-IV.

Assessment of PTSD using a structured interview constitutes the recommended minimum or “core” diagnostic procedure in compensation and pension settings. Structured diagnostic interview assessment has the advantage of enhancing the objectivity, standardization, and consistency of evaluations across settings and examiners.

Routine use of psychometric tests and questionnaires for assessing PTSD and psychopathology may not be feasible in all settings, though many practitioners regularly use these instruments to enhance the comprehensiveness and quality of their evaluation. The clinician’s reliance on psychometric assessment is at the discretion of clinician, and may depend on the professional background of the examiner and availability of personnel trained in use of the relevant methods. However, psychometric assessment is strongly suggested as a supplement to interview methods in complex examination situations. These situations may include but are not limited to (a) claimants who are appealing a rating decision, (b) cases where interview findings are of questionable validity, and (c) veterans having complicated clinical pictures involving multiple and confusing comorbid mental disorders.

Many instruments are available for assessing PTSD. Provided below is a menu of suggested instruments to be used in compensation and pension settings, based on their established reliability and validity, ease of administration, and the fact that no fee is charged for their use. Selection of particular assessment instruments will likely depend on the examiner’s professional background, preferences, and allotted time to complete the assessment. The instruments suggested here are designed to assist the examiner in assessing the presence and severity of PTSD diagnostic criteria (listed below) in a manner that is systematic, objective, and standardized.

DSM-IV Diagnostic Criteria for PTSD

A. The person has been exposed to a traumatic event .

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

2. Recurrent distressing dreams of the event.

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.

2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.

7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep.

2. Irritability or outbursts of anger.

3. Difficulty concentrating.

4. Hypervigilance.

5. Exaggerated startle response.

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

B.2. Diagnostic interview assessment of PTSD.

The Clinician Administered PTSD Scale (CAPS) (Blake et al., 1995) is recommended as the interview method of choice, for conducting compensation and pension examinations for PTSD. The CAPS is a structured clinical interview designed to assess symptoms of PTSD corresponding to DSM-IV criteria.

The CAPS has a number of advantages over other diagnostic interview methods for PTSD, including

(a) the use of explicit behavioral anchors as the basis for clinician ratings,

(b) separate scoring of frequency and intensity dimensions for each PTSD symptom,

(c) measurement of associated clinical features,

(d) assessment of the impact of PTSD symptoms on social and occupational functioning, and

(e) ratings of the validity of information obtained. The CAPS provides dichotomous information about the presence/absence of the PTSD diagnosis as well as overall severity of the disorder. An additional advantage of the CAPS is its sound psychometric structure, with high inter-rater agreement, very high diagnostic sensitivity and specificity, and convergent validity with other measures of PTSD.

The CAPS requires approximately one hour to administer, though it can be customized and abbreviated by eliminating less relevant components. However, other interview-based diagnostic instruments for PTSD are also suitable for use in conducting compensation and pension examinations and require less time to administer. These instruments include the PTSD Symptom Scale (Foa, Riggs, Dancu, & Rothbaum, 1993); Structured Interview for PTSD (Davidson, Malik, & Travers, 1997); Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1995); Anxiety Disorders Interview—Revised (DiNardo & Barlow, 1988); and the PTSD Interview (Watson, Juba, Manifold, Kucala, & Anderson, 1991). Although a modest time savings may result from using these alternative instruments, the information gleaned from them is typically not as comprehensive and, unlike the CAPS, there may be a charge associated with their use.

B.3. Psychometric assessment of PTSD.

Psychometric assessment of PTSD provides quantitative assessment of the degree of PTSD symptom severity. Judgments about symptom severity can be made by comparing an individual’s scores against norms established on reference samples of individuals who are known to have or not have PTSD. Cutting scores have been established for the psychometric measures of PTSD recommended here, based on their high sensitivity and specificity in discriminating individuals with PTSD from those without PTSD. Data from psychometric tests never serve as a “stand alone” means for diagnosing PTSD. Rather, the psychometric measures suggested here should be used to supplement and substantiate findings gleaned from interview assessment and other sources of data, particularly when there is a need to reconcile multiple diagnoses. Use of at least one of the following psychometric instruments is recommended for inclusion in disability evaluations for PTSD, on a routine basis or in cases where testing is selectively administered:

A number of other psychometric instruments are acceptable alternative methods for assessing PTSD. These include, but are not limited to, the MMPI PTSD subscales (Lyons & Keane, 1992), Impact of Event Scale—Revised (Weiss & Marmar, 1997), Penn Inventory (Hammarberg, 1992), PTSD Stress Diagnostic Scale (Foa, 1995), and Trauma Symptom Inventory (Briere, 1995). Additionally, many instruments that provide comprehensive assessment of psychopathology and personality functioning that may supplement PTSD-specific symptom assessment (e.g., MMPI, MCMI, Personality Assessment Inventory). These instruments are useful in quantifying severity of symptoms of other disorders that often co-occur with PTSD and may provide information about possible overstatement of symptoms and test-taking attitude (e.g., defensiveness).

C. Recommended Time Allotment for Completing Examination

This guideline is designed to enhance the objectivity, reliability, and overall quality of PTSD C&P examinations. It is recognized that implementing these recommendations may require more clinician time and institutional resources than is currently devoted to the PTSD assessment. The time required for the conduct of initial PTSD examinations may vary widely, depending on a number of factors. These factors include, but are not limited to, the availability and quantity of records to be reviewed, the existence of objective evidence of clearcut stressors, the veteran’s degree of emotional distress exhibited during trauma assessment, the amount and complexity of comorbid psychopathology, and a number of other veteran-specific factors that may impact the pace of the assessment process.

C&P examinations for PTSD extend far beyond the scope of simply rendering a diagnosis of PTSD, similar to that occurring in a clinical assessment situation. Specific complexities of PTSD assessment in the compensation and pension situation include:

(a) implicit examiner requirements to make complex judgments about potential malingering in the context of an administrative evaluation with obvious financial implications;

(b) VBA requests of examiners to comprehensively diagnose all comorbid mental disorders and partition disability to different disorders in an increasingly chronic veteran population, where co-occurring mental disorders are inextricably related to PTSD; and

(c) requirements of examiners to render an informed opinion about the effects of PTSD on social and occupational functioning. Since examiners are not able to observe the work performance of claimants and they typically do not have access to such observational information, a careful and often time-consuming walk-through of the histories of our aging veteran claimants is required as the foundation for an opinion regarding functional disability.

Initial PTSD compensation and pension evaluations typically require up to three hours to complete, but complex cases may demand additional time. Time estimates for accomplishing components of the examination are as follows:

• Psychosocial history and assessment of change in social and occupational functioning (30 minutes)

• Report preparation (50 minutes)

• Psychometric assessment (additional time required, if administered)

Follow-up evaluations for PTSD do not require a trauma exposure assessment, military history, or comprehensive psychosocial history, and the records review burden is usually less than for an initial examination. These evaluations can typically be completed in about half the time required for an initial PTSD examination. (See Examination Worksheet I [p. 23-29] and Examination Worksheet II [p. 30-34] for a distinction between initial and follow-up examination content.)

Professionals qualified to perform PTSD examinations should have doctoral-level training in psychopathology, diagnostic methods, and clinical interview methods. They should have a working knowledge of DSM-IV, as well as extensive clinical experience in diagnosing and treating veterans with PTSD. Ideally, examiners should be proficient in the use of structured clinical interview schedules for assessing PTSD and other disorders, as well as psychometric methods for assessing PTSD. Board certified psychiatrists and licensed psychologists have the requisite professional qualifications to conduct compensation and pension examinations for PTSD. Psychiatric residents and psychology interns are also qualified to perform these examinations, under close supervision of attending psychiatrists or psychologists.

• disciplinary infractions or other adjustment problems during military

NOTE: Service connection for PTSD requires medical evidence establishing a diagnosis of the condition that conforms to the diagnostic criteria of DSM-IV, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. It is the responsibility of the examiner to indicate the traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD. Crucial in this description are specific details of the stressor, with names, dates, and places linked to the stressor, so that the rating specialist can confirm that the cited stressor occurred during active duty. A diagnosis of PTSD cannot be adequately documented or ruled out without obtaining a detailed military history and reviewing the claims folder. This means that initial review of the folder prior to examination, the history and examination itself, and the dictation for an examination initially establishing PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal.

Post-Military Trauma History (refer to social-industrial survey if completed)

Conduct a brief mental status examination aimed at screening for DSM-IV mental disorders. Describe and fully explain the existence, frequency and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning:

b). Rule our malingering or exaggeration by considering whether the F(p) Scale is elevated, and

c). if Steps a and b are negative, then a high F Scale can be considered consistent with psychopathology.

A hit rate of 97% or greater for F(p) at a cut score of T = 100 was found for both clinical and forensic samples, and taxometric analysis revealed that F(p) cutting cores are stable across non-VA and VA clinical settings and that F(p) raw scores greater than 6 could be classified as overreported (Strong et. al., 2000).

Nonetheless, it is critical that clinicians understand the nature of their population with regard to frequency and type of psychopathology before interpreting the F(p) Scale.

Independent verification that patients are overreporting is needed.

• provide scores for PTSD psychometric assessments administered

• state whether PTSD psychometric measures are consistent or inconsistent with a diagnosis of PTSD, based on normative data and established “cutting scores” (cutting scores that are consistent with or supportive of a PTSD diagnosis are as follows: PCL ≥ 50; Mississippi Scale ≥ 107; MMPI PTSD subscale a score > 28; MMPI code type: 2-8 or 2-7-

• state degree of severity of PTSD symptoms based on psychometric data (mild, moderate, or severe)

1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report.

2. If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship.

3. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning.

NOTE: VA is prohibited by statute, 38 U.S.C. § 1110, from paying compensation for a disability that is a result of the veteran’s own alcohol and drug abuse. However, when a veteran’s alcohol or drug abuse disability is secondary to or is caused or aggravated by a primary service-connected disorder, the veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the relationship, if any, between a service-connected disorder and a disability resulting from the veteran’s alcohol or drug abuse. Unless alcohol or drug abuse is secondary to or is caused or aggravated another mental disorder, you should separate, to the extent possible, the effects of the alcohol or drug abuse from the effects of the other mental disorder(s). If it is not possible to separate the effects in such cases, please explain why.

[Preference is for current level of functioning for C&P purposes, although rating should take into consideration all evidence of functioning, over past year or since previous exam.]

J. GAF

NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning. A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service-connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed. If it is not possible, an explanation as to why not is needed. (See the above note pertaining to alcohol or drug abuse.)

K. Capacity to Manage Financial Affairs

Mental competency, for VA benefits purposes, refers only to the ability of the veteran to manage VA benefit payments in his or her own best interest, and not to any other subject. Mental incompetency, for VA benefits purposes, means that the veteran, because of injury or disease, is not capable of managing benefit payments in his or her best interest.

In order to assist raters in making a legal determination as to competency, please address the following:

What is the impact of injury or disease on the veteran’s ability to manage his or her financial affairs, including consideration of such things as knowing the amount of his or her VA benefit payment, knowing the amounts and types of bills owed monthly, and handling the payment prudently?

Does the veteran handle the money and pay the bills himself or herself?

Based on your examination, do you believe that the veteran is capable of managing his or her financial affairs? Please provide examples to support your conclusion.

If you believe a Social Work Service assessment is needed before you can give your opinion on the veteran’s ability to manage his or her financial affairs, please explain why.

L. Other Opinion

Furnish any other specific opinion requested by the rating board or BVA remand (furnish the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken).

If the requested opinion is medically not ascertainable on exam or testing, please state why.

If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions, say so, and explain why.

If the opinion asks “ ... is it at least as likely as not ... “, fully explain the clinical findings and rationale for the opinion.

M. Integrated Summary and Conclusions

• Describe changes in psychosocial functional status and quality of life following trauma exposure (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits)

• Describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life. Particularly in cases where a veteran is unemployed, specific details about the effects of PTSD and its symptoms on employment are especially important.

• If possible, describe extent to which disorders other than PTSD (e.g., substance use disorders) are independently responsible for impairment in psychosocial adjustment and quality of life. If this is not possible, explain why (e.g., substance use had onset after PTSD and clearly is a means of coping with PTSD symptoms).

• If possible, describe pre-trauma risk factors or characteristics that may have rendered the veteran vulnerable to developing PTSD subsequent to trauma exposure.

• If possible, state prognosis for improvement of psychiatric condition and impairments in functional status.

• Comment on whether veteran should be rated as competent for VA purposes in terms of being capable of managing his/her benefit payments in his/her own best interest.

1. Hospitalizations and outpatient care from the time between last rating examination to the present, UNLESS the purpose of this examination is to ESTABLISH service connection, then the complete medical history since discharge from military service is required.

2. Frequency, severity and duration of psychiatric symptoms.

3. Length of remissions from psychiatric symptoms, to include capacity for adjustment during periods of remissions.

4. Treatments including statement on effectiveness and side effects experienced.

5. Subjective Complaints: Describe fully.

C. Psychosocial Adjustment since the last exam

• legal history (DWIs, arrests, time spent in jail)

• educational accomplishment

• extent of time lost from work over the past 12 month period and social impairment. If employed, identify current occupation and length of time at this job. If unemployed, note in complaints whether veteran contends it is due to the effects of a mental disorder. Further indicate following diagnosis, what factors, and objective findings support or rebut that contention.

• marital and family relationships (including quality of relationships with spouse and children)

Conduct a brief mental status examination aimed at screening for DSM-IV mental disorders. Describe and fully explain the existence, frequency and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning:

• provide specific evaluation information required by the rating board or on a BVA Remand.

• comment on validity of psychological test results

• provide scores for PTSD psychometric assessments administered

• state whether PTSD psychometric measures are consistent or inconsistent with a diagnosis of PTSD, based on normative data and established “cutting scores” (cutting scores that are consistent with or supportive of a PTSD diagnosis are as follows: PCL ≥ 50; Mississippi Scale ≥ 107; MMPI PTSD subscale a score > 28; MMPI code type: 2-8 or 2-7-

• state degree of severity of PTSD symptoms based on psychometric data (mild, moderate, or severe)

1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report.

2. If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship.

3. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning.

NOTE: VA is prohibited by statute, 38 U.S.C. § 1110, from paying compensation for a disability that is a result of the veteran’s own alcohol or drug abuse. However, when a veteran’s alcohol or drug abuse disability is secondary to or is caused or aggravated by a primary service-connected disorder, the veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the relationship, if any, between a service-connected disorder and a disability resulting from the veteran’s alcohol or drug abuse. Unless alcohol or drug abuse is secondary to or is caused or aggravated another mental disorder, you should separate, to the extent possible, the effects of the alcohol or drug abuse from the effects of the other mental disorder(s). If it is not possible to separate the effects in such cases, please explain why.

NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning. A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service-connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed. If it is not possible, an explanation as to why not is needed. (See the above note pertaining to alcohol or drug abuse.)

J. Competency:

Competency, for benefits purposes, has a special meaning, and refers only to veterans’ ability to manage benefit payments in their own best interests without restriction, and not to any other subject. State whether the veteran is capable of managing his/her or her benefit payments in the individual’s own best interests (a physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual’s financial affairs).

K. Capacity to Manage Financial Affairs

Mental competency, for VA benefits purposes, refers only to the ability of the veteran to manage VA benefit payments in his or her own best interest, and not to any other subject. Mental incompetency, for VA benefits purposes, means that the veteran, because of injury or disease, is not capable of managing benefit payments in his or her best interest.

In order to assist raters in making a legal determination as to competency, please address the following:

What is the impact of injury or disease on the veteran’s ability to manage his or her financial affairs, including consideration of such things as knowing the amount of his or her VA benefit payment, knowing the amounts and types of bills owed monthly, and handling the payment prudently?

Does the veteran handle the money and pay the bills himself or herself?

Based on your examination, do you believe that the veteran is capable of managing his or her financial affairs? Please provide examples to support your conclusion.

If you believe a Social Work Service assessment is needed before you can give your opinion on the veteran’s ability to manage his or her financial affairs, please explain why.

L. Integrated Summary and Conclusions

1. Describe changes in psychosocial functional status and quality of life since the last exam (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits).

2. Describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life. Particularly in cases where a veteran is unemployed, specific details about the effects of PTSD and its symptoms on employment are especially important.

3. If possible, describe extent to which disorders other than PTSD (e.g., substance use disorders) are independently responsible for impairment in psychosocial adjustment and quality of life. If this is not possible, explain why (e.g., substance use had onset after PTSD and clearly is a means of coping with PTSD symptoms).

4. If possible, state prognosis for improvement of psychiatric condition and impairments in functional status.

5. Comment on whether veteran should be rated as competent for VA purposes in terms of being capable of managing his/her benefit payments in his/her own best interest.

The following template includes examples of all information listed in the Initial Disability Examination worksheet, and is intended as an aid to organizing information gained during the examination. Taking into account the individual differences in patients, clinician specialty, writing style, and resources and time available, it is recommended that the examiner utilize clinical judgment in choosing which template options are particularly relevant to documenting a thorough assessment and diagnosis of the veteran.

Name:
Date:
Address:
Clinician:
DOB:
Supervisor:
SS#:

1. Identifying information & Referral Question
The veteran is a __ year old, ____ (race), _____ war era veteran , living with
______ for the past _______, referred to the C&P program, _______ division for
a comprehensive evaluation for the diagnosis of PTSD. General remarks on the
2507 form request ____________________.

2. Sources of Information
The veteran was interviewed for approximately ___ hour(s) on (date) ______.
In addition, a review was made of his/her C-file / DD-214, / medical records
from VA, Department of Defense, and other health care facilities. In addition,
the veteran saw (social worker) ____________ on (date) ______ who conducted
a comprehensive psychosocial history. Additionally, the veteran saw Dr. ______
on (date) __________ who diagnosed the veteran with ____________,
_____________________________. Other sources of information include statements
from collaterals or others who have information about the veteran’s trauma
exposure and its behavioral sequelae, evidence of behavior changes that
occurred shortly after the trauma incident, and statements derived from interview
of the claimant. These will be cited where appropriate as sources of information
below.
The veteran was administered a battery of psychometric tests to assess psychopathology
and specific symptoms of PTSD. Instruments utilized included
the following (choose): Mississippi Scale for Combat Related PTSD, the
Combat Exposure Scale, the PCL, a modified version of the Structured Clinical
Interview for DSM-IV PTSD module, the Women’s Wartime Stressor Scale, the
Desert Storm Trauma Exposure Questionnaire, the Sexual Experiences Survey,
the Childhood Trauma Questionnaire, the MMPI PTSD subscales, the Impact
of Event Scale—Revised, the Penn Inventory , the PTSD Stress Diagnostic
Scale, and the Trauma Symptom Inventory. The assessments were administered
at the time of this interview. Results will be reported below.

1. Premilitary History and Functioning
The veteran was raised by his/her biological / adoptive / step parents until the
age of ____, at which time he/she enlisted in the (military branch) ___________.
His/her father was described as (type of work, personality):
___________________, and his/her mother as (type of work, personality)
___________________________________. He/she has (#) _________ siblings
who currently are ages _______, and living in _______________________.
He/she maintains that he/she has(type of relationship; contact)
__________________________ with parents and (type of relationship; contact )
__________________ with his/her siblings.
Prior to entering the service, the veteran completed ______ years of schooling
and earned / did not earn a high school diploma. He describes him/herself during
this time as being “ __________, ” and his/her pre-military adjustment as
being / very good / good / average / marginal / poor. His/her performance in
school, grades, suspensions, general behavior, sports participation, dating were
____________. Legal history included: _______________________________.
He/she had ________ history of trouble as a youth which he/she described as
___________________________________. His/her college history is __________.
His/her substance usage was reported to be ___________________________ and
included the use of (types) ____________ with (no) associated problems including:
_______________________. He/she had health-related problems which
included (include history of injury, including head injury) __________________.
According to the veteran’s reports, his/her pre-military stressors included:
_______________________, at ages ______, resulting in (academic problems,
hospital, jail, mental symptoms, treatment, etc). ___________. Medications
taken regularly prior to military included _____________________.
Family history of psychiatric problems included: ________________________.
Overall assessment of psychosocial adjustment, progression through developmental
milestones, and general level of functioning is: ____________________
_________________________________________.

2. Military History
According to military records and self-report, the veteran __________ was
enlisted / was drafted / commissioned in (branch ________ ) from _______ to
_______. He/she was stationed for (months/years) ____ in (location/s)
________________________, from (dates) _________ to ________. His/her primary
duty was ____________.
In addition, other duties included ________________________________.
He/she served _________ tours in (war) __________ with the (unit)
______________ as (MOS & Duties) _________ in the areas of (location)
_______ from (dates) _________ to _________. He/she attained the rank of
_____ while in (war) ______. He/she was /honorably / dishonorably / generally /
discharged. The veteran’s duty in (war) ______ could be classified as mainly
combat / combat support / support. The veteran was awarded _________
medals. The veteran reported the following general war experiences: (see:
Combat Scale): ______________.
Specific Trauma’s will be discussed below in Section VIII.

3. Post-Military History

Education and Employment History:
The veteran received ______________ education following active duty, with a
__________ certificate / degree(s) achieved. His/her employment history
includes _______________ jobs from _________ to ___________. He/she is currently
unemployed / employed. His/her current occupation is ____________ and
length of time at this job has been __________.

Social Functioning:
The veteran is currently Married/Divorced (onset and length of time for each,
reason for divorce): _______________________. He/she has __________ contact
(with spouse & children). His/her children are (ages) ________________.
He/she describes his/her current relationships as: _________________________.
His/her attitude towards social interactions, and how he/she feels others view
him/her appears to be: ____________________________________________.
His/her social support & hobbies include: ___________________________.

Post Military Stressors:
According to the veteran’s reports, his/her post-military stressors and significant
losses have included: _______________________, at ages ______________.

Legal History:
The veteran’s legal history includes the following incidents (reckless driving,
DWI, assault, etc.) ___________________ on (dates for each) ______________,
which resulted in ______________________.

History of Psychiatric care:
The Veteran’s history of psychiatric care began on ________________, and has
included (medications, inpatient treatment, outpatient care, groups, etc).
___________________. The veteran is currently receiving (type and frequency
of treatment) ________________.
History and length of remissions, have been ___________________. His/her
capacity for adjustment during periods of remissions appeared to be
_________________________.

Social Impairment:
The extent of social impairment and work impairment (time lost, problems with
supervisors/coworkers, loss of productivity, etc.) over the past 12 month period
was ________________________. (If unemployed), The veteran does not contend
/ contends it is due to the effects of a mental disorder. (Further discuss in
DIAGNOSIS, if possible, what factors and objective findings support or rebut
that contention).

7. Testing Results
The veteran was administered measures specifically designed to assess PTSD.

OPTION 1:
In summary, the psychometric findings are consistent with information gathered
during the diagnostic and social history interviews for the presence and level of
symptomatology. On all measures he or she scored in a manner similar to normative
patient samples known to have PTSD. (Scores are suggestive of an individual
with Mild / Moderate / Severe PTSD.) OR The veteran scored in a
range that is characteristic of patient samples that do not carry the diagnosis of
PTSD. The pattern among the psychometric findings supports / does not support
a diagnosis of PTSD.

OPTION 2:
In summary, the psychometric findings are inconsistent with information gathered
during the diagnostic and social history interviews for presence and level
of symptomatology. The level of reporting on the battery of psychometrics is
greater than / less than / more variable than interview information. The discrepancy
may be due to (discuss reasons why the two sources do not agree):
_____________. Given this inconsistency, conclusions about a PTSD diagnosis
based on the psychometric findings cannot be advanced.
Mississippi: ___________ PCL: __________ Combat Exposure Scale:
_______ Women’s Wartime Stressor Scale: ________ Sexual Experiences
Survey: ___________ Brief Questionnaire for Sexual Assault:
_________________ Desert Storm Trauma Exposure Questionnaire:
_____________ Childhood Trauma Questionnaire: ___________ MMPI PTSD
subscales: ________________ Impact of Event Scale—Revised: ____________
Penn Inventory: _____________ PTSD Stress Diagnostic Scale: _____________
Trauma Symptom Inventory: _________ Other:_________

Military Stressor(s)
(To follow from Combat Exposure Questionnaire and interview):
The veteran’s military-related stressors have included injury / captivity / torture
/ witnessing atrocities / personal assault / sexual assault / other. Because there
is a history of multiple stressors, the veteran considers the most severe to have
been ___________________. The impact of each is believed to have been:
a: _______________ b: ________________ c:__________________
d: ______________. Other stressful life events during this period included (noncombat
events such as death in family, etc): _________________________.

Symptoms and impairment in functioning:
(To follow from SCID/CAPS):
Behavioral, cognitive, social, or affective changes linked to the veteran’s military
stressor(s) have included: ______________. Related somatic symptoms
have included: ______________________________. One of his/her most bothersome
symptoms seems to be ____________________.

PTSD Symptoms include:

A. The veteran has been exposed to a traumatic event in which both of the following were present:

• The veteran experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

B. The traumatic event is persistently re-experienced in one or more of the following ways:

• Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

• Recurrent distressing dreams of the event.

• Acting or feeling as if the traumatic event were recurring includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those which occur on awakening or when intoxicated).

• Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

• Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:

• Efforts to avoid thoughts, feelings, or conversations associated with the trauma

• Efforts to avoid activities, places, or people that arouse recollections of the trauma

• Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:

• difficulty falling or staying asleep

• irritability or outbursts of anger

• difficulty concentrating

• hypervigilance

• exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, D) is more than 1 month

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:
Acute: if duration is less than 3 months
Chronic: if duration is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

7. Impression:

The overall picture is one of an individual who had made a / satisfactory / poor /
adjustment prior to entering military service to the extent that there were / no /
many / gross indications of behavior control problems, subjective unhappiness
or family dysfunction. The veteran did struggle in (date, age) _______________,
and he/she did / did not / appear to come from a deprived or abusive background
or exhibit early life disturbances of conduct that would predict his/her
psychiatric and psychosocial adjustment problems as an adult. Prior to entering
the military, the veteran did / did not appear to suffer from symptoms
of PTSD / other.

The veteran’s PTSD symptoms /appear to be/do not appear to be/ related to
changes in impairment in functional status and quality of life (describe)
___________.

OPTION 1: Disorders other than PTSD (e.g., substance use disorders) are
independently responsible for impairment in psychosocial adjustment and quality
of life (describe) _______________.

OPTION 2: At this time, it is not possible, to separate the effects of PTSD and
co-occurring disorders on the veteran’s functioning because ___________ (e.g.,
substance use had onset after PTSD and clearly is a means of coping with
PTSD symptoms).

Pre-trauma risk factors or characteristics than may have rendered the veteran
vulnerable to developing PTSD subsequent to trauma exposure are ______.
Prognosis for improvement of psychiatric condition and impairments in functional
status is ______________.

**The following template includes examples of all information listed in the Follow-up Disability Examination worksheet, and is intended as an aid to organizing information gained during the examination. Taking into account the individual differences in patients, clinician specialty, writing style, and resources and time available, it is recommended that the examiner utilize clinical judgement in choosing which template options are particularly relevant to documenting a thorough assessment and diagnosis of the veteran.**

Name:
Date:
Address:
Clinician:
DOB:
Supervisor:
SS#:

1. Identifying Information & Referral Question
The veteran is a __year old, ____ (race), _____war era veteran, living with
______ for the past _______, referred to the C&P program, _______ division for
a follow-up evaluation for compensation and pension for PTSD.

2. Sources of Information
The veteran was interviewed for approximately ___ hour(s) on (date) ______.

In addition, a review was made of his/her C-file / DD-214, / medical records
from VA, Department of Defense, and other health care facilities. In addition,
the veteran saw (social worker) ____________ on (date) ______ who conducted
a comprehensive psychosocial history. Additionally, the veteran saw Dr. ______
on (date) __________ who diagnosed the veteran with ____________,
_____________________________. Other sources of information include statements
from collaterals or others who have information about the veteran’s trauma
exposure and its behavioral sequelae, evidence of behavior changes that
occurred shortly after the trauma incident, and statements derived from interview
of the claimant. These will be cited where appropriate as sources of information
below.

The veteran was administered a battery of psychometric tests to assess psychopathology
and specific symptoms of PTSD. Instruments utilized included
the following (choose): Mississippi Scale for Combat Related PTSD, the
Combat Exposure Scale, the PCL, a modified version of the Structured Clinical
Interview for DSM-IV PTSD module, the Women’s Wartime Stressor Scale, the
Desert Storm Trauma Exposure Questionnaire, the Sexual Experiences Survey,
the Childhood Trauma Questionnaire, the MMPI PTSD subscales, the Impact
of Event Scale—Revised, the Penn Inventory , the PTSD Stress Diagnostic
Scale, and the Trauma Symptom Inventory. The assessments were administered
at the time of this interview. Results will be reported below.

3. History Since Last C & P Exam

Education and Employment History:
The veteran received ______________ education, with a __________ certificate /
degree(s) achieved. His/her employment history includes _______________ jobs
from _________ to ___________. He/she is currently unemployed / employed.
His/her current occupation is ____________ and length of time at this job has
been __________.

Social Functioning:
The veteran is currently Married/Divorced (onset and length of time for each,
reason for divorce): _______________________. He/she has __________ contact
(with spouse & children). His/her children are (ages) ________________.
He/she describes his/her current relationships as: _________________________.
His/her attitude towards social interactions, and how he/she feels others view
him/her appears to be: ____________________________________________.
His/her social support & hobbies include: ___________________________.

Stressors:
According to the veteran’s reports, his/her stressors and significant losses since
the last C & P exam have included: _______________________.

Legal History:
The veteran’s legal history includes the following incidents (reckless driving,
DWI, DV etc.) ___________________ on (dates for each) ______________,
which resulted in ______________________.

History of Psychiatric care:
Since his/her last C & P exam, the veteran reported the following psychiatric
symptoms (onset, frequency, severity and duration, suicide attempts)
____________________________________________________ . His/her most
troublesome / frequent / disruptive symptoms appear to be
_____________________. His/her history of psychiatric care has included (medications,
inpatient treatment, outpatient care, groups, etc). ______________.
The veteran is currently receiving (type and frequency of treatment)
__________.
History and length of remissions, have been ___________________. His/her
capacity for adjustment during periods of remissions appeared to be
_________________________.

Social Impairment:
The extent of social impairment and work impairment (time lost, problems with
supervisors/coworkers, loss of productivity, etc.) since the last C & P examination
was ________________________. (If unemployed), The veteran does not
contend / contends it is due to the effects of a mental disorder. (Further discuss
in DIAGNOSIS, if possible, what factors and objective findings support or
rebut that contention).

5. Testing Results
The veteran was administered measures specifically designed to assess PTSD.

OPTION 1:
In summary, the psychometric findings are consistent with information gathered
during the veteran’s initial C & P examination for PTSD. On all measures
he/she scored in a manner similar to normative patient samples known to have
PTSD. (Scores are suggestive of an individual with Mild / Moderate / Severe
PTSD.) OR The veteran scored in a range that is characteristic of patient
samples that do not carry the diagnosis of PTSD. The pattern among the psychometric
findings supports / does not support a diagnosis of PTSD.

Symptoms and impairment in functioning:
(To follow from SCID/CAPS):
Behavioral, cognitive, social, or affective changes linked to the veteran’s military
stressor(s) have included: ______________. Related somatic symptoms
have included: ______________________________. One of his/her most bothersome
symptoms seems to be ____________________.

PTSD Symptoms include:

A. The veteran has been exposed to a traumatic event in which both of the following were present:

1. The veteran experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

B. The traumatic event is persistently re-experienced in one or more of the following ways:

- Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.

- Recurrent distressing dreams of the event.

- Acting or feeling as if the traumatic event were recurring includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those which occur on awakening or when intoxicated).

- Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

- Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:

- Efforts to avoid thoughts, feelings, or conversations associated with the trauma

- Efforts to avoid activities, places, or people that arouse recollections of the trauma

- Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:

- difficulty falling or staying asleep

- irritability or outbursts of anger

- difficulty concentrating

- hypervigilance

- exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, D) is more than 1 month

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:
Acute: if duration is less than 3 months
Chronic: if duration is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

8. Impression:

The overall picture is one of an individual who had made a / satisfactory / poor /
adjustment since his/her last C & P examination for PTSD, to the extent that
there were / no / many / gross indications of behavior control problems, subjective
unhappiness or family dysfunction

The veteran’s PTSD symptoms /appear to be/do not appear to be/ related to
changes in impairment in functional status and quality of life (describe)
___________.

OPTION 1: Disorders other than PTSD (e.g., substance use disorders) are
independently responsible for impairment in psychosocial adjustment and quality
of life (describe) _______________.

OPTION 2: At this time, it is not possible, to separate the effects of PTSD and
co-occurring disorders on the veteran’s functioning because ___________ (e.g.,
substance use had onset after PTSD and clearly is a means of coping with
PTSD symptoms).

Prognosis for improvement of psychiatric condition and impairments in functional
status is ______________.

We recently completed a review of 143 initial claims for PTSD, with the assistance of reviewers from the field, under a special protocol. An additional 77 cases were informally reviewed.

The attached training letter addresses some of our general findings as well as problems revealed by the review. The 10 important rating points about PTSD emphasize major areas of concern. They are followed by more detailed information on our findings.

Additional and broader training on PTSD will be conducted in the near future. This letter is not intended to make policy but to restate and clarify existing policy.

1. You are obligated (per 4.125) to assure that the diagnosis of PTSD is well-supported by the findings and is based on DSM-IV diagnostic criteria. Return examination reports that do not meet this requirement.

2. You must rate PTSD based on its overall effects on social and occupational functioning. Return examination reports that do not describe these effects in detail.

3. A veteran does not need to have any or all of the specific examples of signs and symptoms listed in the general rating formula for mental disorders in order for a particular evaluation level of PTSD to be assigned.

4. Evaluate PTSD on the core requirements at each evaluation level, i.e., the language that refers to the effects of a mental disorder on social and occupational functioning.

5. Make sure you have made reasonable efforts to obtain all pertinent evidence (consistent with the new duty to assist requirements), including private medical records the veteran may have referred to, before you make an unfavorable decision.

6. Don’t go through the I.U. process if there is clear evidence on the examination that the veteran is unable to work because of PTSD. A 100% evaluation would be more appropriate in such cases, and a future exam can be requested when indicated.

7. Do not base a rating solely or mainly on the GAF score. The GAF score does not translate directly to the rating schedule criteria.

8. Do not ignore additional mental disorders that are diagnosed in someone with PTSD. Ask the examiner about the relationship to PTSD if not already addressed in the examination report.

9. Explain the reasons for all of your rating decisions.

10. You must notify the veteran in clear terms of the rating decisions and fully inform him or her of any action necessary to further or complete the claim for PTSD.

What were our general findings in the review?

• 127 of the 143 decisions reviewed (89%) correctly disposed of the basic issue of service connection.

Most reviewed cases were correctly evaluated, but of those that were not, most were underevaluated. Granted that evaluating any mental disorder is difficult, the reason these cases were underevaluated is unclear because of the failure to analyze evidence and explain the rating decision in the reasons and bases. As a rule, ratings laid out the evidence and gave the conclusion, but did not address how the rater reached the decision. The rating redesign initiative directly addresses this issue, as well as our organizational expectations concerning the fix.

2. Problem in applying rating schedule criteria

One reason for erroneous evaluations may be confusion about the criteria in the general rating formula for mental disorders. The signs and symptoms named at each level are examples of what might be seen at each level. However, the absence of those specific findings in an individual does not exclude a rating at any given level.

It is the described effects on social and occupational functioning at each level of whatever signs and symptoms the veteran has that should determine the rating. In particular, the examples of signs and symptoms given do not encompass the common diagnostic findings specific to PTSD, but apply to any mental disorder. Therefore, you must look beyond the generic signs and symptoms in the rating schedule and look at the effects of PTSD in that individual. As with other disabilities, there is often a difference between the findings that establish the diagnosis of PTSD and those that indicate its level of severity.

Example: Vietnam combat veteran reported or showed:

• sleep disturbances to point of getting only 3-4 hours of sleep a night

• avoidance of most people and social events, distant and estranged from others

• restricted range of affect

• aggressive outbursts at work indicating impaired judgment in thinking (almost threw a man off a building, drove a vehicle into something else and caused damage)

• withdrawn, decreased concentration, hypervigilance

• mood depressed and hopeless, suicidal ideation

• fatigued and irritable

• hallucinatory flashbacks

• impairment in reality testing

Some of these are examples (in the general rating formula for mental disorders) of signs and symptoms at the 70-percent evaluation level, and others are more akin to the 100-percent level. Some of his significant problems are not in either list of examples. Taking into account all of the findings, it is clear he is at least severely, if not totally, impaired in both social and occupational functioning. He was given a 70% evaluation. Others might judge a 100% evaluation as more appropriate, particularly in view of the episodes of violence.

The National PTSD Center points out to examiners in soon-to-be-released guidelines for PTSD examiners that the presence of violence toward self and others in the veteran’s history is a significant feature that should drop the GAF score into the lower ranges, even if functioning in other areas appears better. This indicates the Center’s belief that violence should be regarded as an indication of very serious disease.

3. Reluctance to grant 100%

Many cases of PTSD were rated at 70% even when there were clear indications on the examination that the veteran had severe symptoms and had total occupational impairment because of PTSD symptoms.

Examples: One veteran had not been working for 2 years because of PTSD symptoms; one was reported as unable to work and getting progressively worse; one had not worked for 7 or 8 months since seeing “Saving Private Ryan”; one was complying with his treatment plan but was said not to be sufficiently stable (e.g., had suicidal ideation) to maintain competitive employment; one was said to have an inability to function in almost all areas; and one had impairment of reality testing, active flashbacks, depression, hopeless mood, etc.

Each of these was rated at 70% but could have been rated at 100%. GAF scores in these cases ranged from 30 to 45. (30 was the lowest GAF score given for any case in this review.) Most were eventually given I.U., but there seemed to be great reluctance to grant a schedular 100-percent evaluation even when there was ample medical evidence of severe disability due to PTSD, and a clear indication of impaired functioning sufficient for a schedular 100-percent evaluation.

The old Physician’s Guide stated in the chapter on mental disorders: “In the case of anxiety disorders, except for severe phobias, it is unusual for a person to be completely incapacitated.” However, VA’s National Center for PTSD states that anxiety disorders, severe phobias, PTSD, OCD (obsessive-compulsive disorder), panic disorder (esp. with agoraphobia), and social phobia all can be debilitating, sometimes to the point of complete incapacitation. Currently, over 29,000 veterans with PTSD are rated at 100% and over 6000 with generalized anxiety disorder are rated at 100%. Therefore, it is no longer correct to say that total incapacitation for anxiety disorders is unusual.

What problem was found on notification letters?

A common problem noted in the review was the failure to provide correct and adequate notification letters. A letter notifying a claimant about a rating should not simply refer to an attached copy of a rating for all information, only for a more detailed explanation of what is summarized in the notification letter itself (See M21-1, Part III, 11.09a and FL 00-58.)

What are the examination-related problems?

1. Availability of claims file

The examiner had the claims file for review in less than half the cases. Since these were all initial PTSD claims, this was a significant omission. We are addressing this issue with VHA and will also discuss it on the satellite broadcast.

2. Inadequacy of exams

Examinations were largely adequate, but of those that were not adequate, few were returned for correction or completion.

Example: One examiner said the veteran seemed to have some minor PTSD symptoms—but did not name them. This was the only reference to PTSD in the examination, and the veteran was SC and evaluated for PTSD based on this exam. The examination should have been returned to get more specific information.

3. Failure to apply DSM-IV criteria

In good exams, the examiner listed the DSM-IV criteria and supplied examples of the veteran’s own signs and symptoms that met those criteria. When this procedure is followed, the rater should have few reservations about the validity of the diagnosis.

In several cases, the examiner clearly used DSM-III-R criteria, and they were accepted as adequate for rating, contrary to regulations (38 CFR 4.125). If you read the DSM-III-R and DSM-IV diagnostic criteria, the differences will be obvious. The language used by the examiner will usually make it clear which version is the basis of the diagnosis.

Example: Examiner began explanation of PTSD diagnosis by stating that the veteran has experienced an event that is outside the range of usual human experience and would have been markedly distressing to almost anyone. These are DSM-III-R, but not DSM-IV, criteria and are a clear indication that the diagnosis is not based on DSM-IV criteria.

What are some problems related to the use of GAF Scores?

1. Failure to explain how GAF score was used.

The GAF score was always reported in ratings when it was available, but how it was used or taken into account, if it was, was rarely explained. In some cases, however, the GAF score was the only apparent justification for the evaluation.

Example: Rating stated GAF of 60 is indicative of moderate symptoms, and therefore 30% is assigned.

The GAF scale is generally acknowledged to be an unreliable tool for assessment, although it may have value for treatment and prognostic purposes. No rating should be based primarily or even substantially on the GAF score.

2. Timeframe of GAF score.

The GAF is simply an indicator of an examiner’s assessment of overall functioning, and the period of time it represents differs with different examiners. Common timeframes are either current level of functioning or best level of functioning during the past year. Which is intended is not always explained in the examination report.

While current functioning is the more useful of the two for our purposes, it is really only of interest if the veteran has been relatively stable over the past year or since the last examination. Remember that we are to consider all evidence of record, including any periods of remission, to attain a comprehensive picture of functioning. Taking this into account might lead you to an evaluation that is not consistent with the examiner’s GAF score but which is more appropriate to rating requirements.

How should the GAF score be used?

You might want to look upon the GAF score as a finding that you could use as a crosscheck against your own evaluation based on the reported signs and symptoms. The GAF score, your evaluation based on the rating schedule, and the reported signs and symptoms should theoretically all correlate with one another. If they do not, you should carefully reexamine the evidence, and perhaps explain in the rating why your evaluation is at substantial variance with the GAF score, when it is, perhaps, for example, because of different timeframes. If the GAF score is not supported by other information in the examination report, it has little or no value.

However, there is no reason to change an evaluation because a GAF score differs in the assessed level of functioning from your evaluation, because your assessment may be based on more complete information than the examiner has.

Example: One examiner reported that the criteria that best describe the veteran are mild impairment with occasional decrease in efficiency due to such symptoms as depressed mood, anxiety, chronic sleep impairment, and mild memory loss (part of the 30% criteria from the general rating formula for mental disorders), which reflects a GAF score of 55. In essence, he was making a rating schedule determination and correlating the GAF to it, rather than linking the GAF score to the clinical findings.

What are the problems in duty to assist?

In some cases where it seemed indicated, all private medical records were not requested, the SMRs were not requested, there was no U.S. Armed Services Center for Unit Records Research (CURR) request, pertinent service personnel records were not requested, or all VA medical records were not requested. You should not deny a claim until you are sure that all requested evidence has been received (or the reason why it could not be obtained noted), the claimant has been afforded the opportunity to obtain and submit evidence, and
you have sought relevant evidence from available sources.

How often was CURR used for stressor verification?

CURR stressor verification was used in 4 of the 6 cases where it was required.

CURR verified the stressor in one of these 4 cases.

How should other diagnosed mental disorders be handled?

When comorbid (co-existing) mental disorders were present, the examiner did not always comment on their relationship to PTSD. Ratings often failed to address co-existing disorders in any way or to ask the examiner to determine whether they were related to or part of PTSD. Since depression, for example, and substance abuse are both common accompaniments to PTSD and are sometimes due to or part of PTSD, mental disorders diagnosed in addition to PTSD cannot be ignored in ratings. If the examiner doesn’t make it clear whether they are distinct and unrelated entities, the examination should be
returned to clarify that.

A related problem is the need to reconcile varying diagnoses. Clarification is necessary if the examination upon which you are basing a rating makes a different diagnosis from a diagnosis or diagnoses in other evidence of record. This is required by 38 CFR 4.25(b), which states: ” the rating agency shall determine whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. If it is not clear from the available records what the change of diagnosis represents, the rating agency shall return the report to the examiner for a determination.” This was not routinely done.

What are examples of erroneous grants and denials?

1. Premature grants

PTSD may occur as an acute condition that resolves after a severely stressful experience. Therefore, it cannot always be assumed to be a chronic disease.

Example: SC at 50% granted. Had PTSD in svc. Has no current diagnosis. Veteran did not appear for exam. Reason for separation was personality disorder.

Example: SC at 10% granted. Had PTSD in service related to Lebanon embassy bombing. Exam is inadequate—gives history of PTSD—but it is unclear whether he now has PTSD.

Example: SC at 50% granted for PTSD with major depression. Stressors were explosion on ship and abandonment by wife. Rating does not discuss SMRs (had a medical board) or VA examination, does not state why PTSD is SC, and does not indicate the basis of the evaluation.

3. SC grant based on inadequate exams

Example: 2 cases where SC at 10% was granted where the diagnosis was made only by the VHA POW exam coordinator (who is not a mental health professional). One did have an examination by a mental health professional. While inadequate, it did not diagnose PTSD.

Example: SC at 10% granted. Record of hospitalization for depression, and VAE showed bipolar disorder and PTSD. Criteria for PTSD were not laid out and psychological tests did not support a PTSD diagnosis. Report should have been returned for clarification and
explanation.

Example: SC 70%. Vietnam combat veteran. Examiner says there is inability to function in almost all areas. GAF 30, the lowest GAF given in this group of reviewed cases. To consider I.U. Should have been given 100%.

Overevaluation

Example: SC 70% in 86 year old WWII veteran with Purple Heart. GAF 62. Barely meets PTSD criteria. Has mild dementia. Grossly overevaluated because there is no indication he is severely disabled, even taking into account his mild dementia.

3.304 Direct service connection; wartime and peacetime.
* * * * *
Posttraumatic stress disorder. Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. If the evidence establishes that the veteran was a prisoner-of-war under the provisions of 3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. (Authority: 38 U.S.C. 1154(b))

The issue of service connection for PTSD is the sole responsibility of the rating specialist at the local level. Central Office opinion or guidance may be requested on complex cases.

a. Stressors.

In making a decision, exercise fair, impartial, and reasonable judgment in determining whether a specific case of PTSD is service connected. Some relevant considerations are:

(1) PTSD does not need to have its onset during combat. For example, vehicular or airplane crashes, large fires, flood, earthquakes, and other disasters would evoke significant distress in most involved veterans. The trauma may be experienced alone (rape or assault) or in the company of groups of people (military combat).

(2) A stressor is not to be limited to just one single episode. A group of experiences also may affect an individual, leading to a diagnosis of PTSD. In some circumstances, for example, assignment to a grave registration unit, burn care unit, or liberation of internment camps could have a cumulative effect of powerful, distressing experiences essential to a diagnosis of PTSD.

(3) PTSD can be caused by events which occur before, during or after service. The relationship between stressors during military service and current problems/symptoms will govern the question of service connection. Symptoms must have a clear relationship to the military stressor as described in the medical reports.

(4) PTSD can occur hours, months, or years after a military stressor. Despite this long latent period, service-connected PTSD may be recognizable by a relevant association between the stressor and the current presentation of symptoms. This association between stressor and symptoms must be specifically addressed in the VA examination report and to a practical extent supported by documentation.

(5) Every decision involving the issue of service connection for PTSD alleged to have occurred as a result of combat must include a factual determination as to whether or not the veteran was engaged in combat, including the reasons or bases for that finding. (See Gaines v. West, 11 Vet. App. 113 (1998).)

b. Evidence of Stressors in Service

(1) Conclusive Evidence.

Any evidence available from the service department indicating that the veteran served in the area in which the stressful event is alleged to have occurred and any evidence supporting the description of the event are to be made part of the record. Corroborating evidence of a stressor is not restricted to service records, but may be obtained from other sources (see Doran v. Brown, 6 Vet. App. 283 (1994)). If the claimed stressor is related to combat, in the absence of information to the contrary, receipt of any of the following individual decorations will be considered evidence of participation in a stressful episode:

Other supportive evidence includes, but is not limited to, plane crash, ship sinking, explosion, rape or assault, duty on a burn ward or in graves registration unit. POW status which satisfies the requirements of 38 CFR 3.1(y) will also be considered conclusive evidence of an in-service stressor.

(2) Evidence of Personal Assault
.
Personal assault is an event of human design that threatens or inflicts harm. Examples of this are rape, physical assault, domestic battering, robbery, mugging, and stalking. If the military record contains no documentation that a personal assault occurred, alternative evidence might still establish an in-service stressful incident. Behavior changes that occurred at the time of the incident may indicate the occurrence of an in-service stressor. Examples of behavior changes that might indicate a stressor include (but are not limited to):

• Visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment;

• Sudden requests that the veteran’s military occupational series or duty assignment be changed without other justification;

• Lay statements indicating increased use or abuse of leave without an apparent reason such as family obligations or family illness;

• Changes in performance and performance evaluations;

• Lay statements describing episodes of depression, panic attacks, or anxiety but no identifiable reasons for the episodes;

• Treatment for physical injuries around the time of the claimed trauma but not reported as a result of the trauma; and

• Breakup of a primary relationship.

In personal assault claims, secondary evidence may need interpretation by a clinician, especially if it involves behavior changes. Evidence that documents such behavior changes may require interpretation in relationship to the medical diagnosis by a VA neuropsychiatric physician.

(3) Credible Supporting Evidence.

A combat veteran’s lay testimony alone may establish an in-service stressor for purposes of service connecting PTSD (Cohen v. Brown, 94-661 (U.S. Ct. Vet. App. March 7, 1997)). However, a noncombat veteran’s testimony alone does not qualify as “credible supporting evidence” of the occurrence of an inservice stressor as required by 38 CFR 3.304(f). After-the-fact psychiatric analyses which infer a traumatic event are likewise insufficient in this regard (Moreau v. Brown, 9 Vet. App. 389 (1996)).

d. Incomplete Examinations and/or Reconciliation of Diagnosis.

If an examination is received with the diagnosis of PTSD which does not contain the above essentials of diagnosis, return the examination as incomplete for rating purposes, note the deficiencies, and request reexamination.

(1) Examples of an unacceptable diagnosis include not only insufficient symptomatology, but failure to identify or to adequately describe the stressor, or failure to consider prior reports demonstrating a mental disorder which could not support a diagnosis of PTSD. Conflicting diagnoses of record must be acknowledged and reconciled.

(2) Exercise caution to assure that situational disturbances containing adjustment reaction of adult life which subside when the situational disturbance no longer exists, or is withdrawn, and the reactions of those without neurosis who have “dropped out” and have become alienated are not built into a diagnosis of PTSD.

e. Link Between In-service Stressor and Diagnosis.

Relevant specific information concerning what happened must be described along with as much detailed information as the veteran can provide to the examiner regarding time of the event (year, month, day), geographical location (corps, province, town or other landmark feature such as a river or mountain), and the names of others who may have been involved in the incident. The examining psychiatrist or psychologist should comment on the presence or absence of other traumatic events and their relevance to the current symptoms. Service connection for PTSD will not be established either on the basis of a diagnosis of PTSD unsupported by the type of history and description or where the examination and supporting material fail to indicate a link between current symptoms and an in-service stressful event(s).

f. Review of Evidence

(1) If a VA medical examination fails to establish a diagnosis of PTSD, the claim will be immediately denied on that basis. If no determination regarding the existence of a stressor has been made, a discussion of the alleged stressor need not be included in the rating decision.

(2) If the claimant has failed to provide a minimal description of the stressor (i.e., no indication of the time or place of a stressful event), the claim may be denied on that basis. The rating should specify the previous request for information.

Excerpts from VBA’s Adjudication Procedures Manual concerning
the development of PTSD claims based on personal assault

5.14 POST TRAUMATIC STRESS DISORDER (PTSD)

PTSD Claims Based on Personal Assault

(2) Because assault is an extremely personal and sensitive issue, many incidents of personal assault are not officially reported, and victims of this type of in-service trauma may find it difficult to produce evidence to support the occurrence of the stressor. Therefore, alternative evidence must be sought.

(4) (a) Service records not normally requested may be needed to develop this type of claim. Responses to the development letter attachment shown in Exhibit B.11 may identify additional information sources. These include:

A rape crisis center or center for domestic abuse,

A counseling facility,

A health clinic,

Family members or roommates,

A faculty member,

Civilian police reports,

Medical reports from civilian physicians or caregivers,

A chaplain or clergy, or

Fellow service persons.

(b) Any reports from the military police, shore patrol, provost marshal’s office,
or other military law enforcement.

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Appendix D: Detailed Guideline For the GAF

Use of the GAF score (DSM-IV Axis V) as a clinical outcome measure has gained increased prominence in both private and public mental health settings. In the late 1990’s, the Department of Veterans Affairs mandated that a GAF score be assigned at regular intervals for veterans receiving care in the system. Disability boards have at times also employed the GAF as an index of a claimant’s functional status as part of the process of determining eligibility for benefits. The GAF is appealing as a rating of functioning because it is:

1) widely available

2) intuitive in its intended goal

3) ostensibly time-efficient, and

4) a scaled value linked to symptoms or functioning

The appeal of GAF is also understandable in the context of Compensation and Pension determinations because it is viewed as a quick and easy measure to assign and one that is easily understood by a wide range of people without advanced education or special training. Existing literature on the development of the GAF indicates that it was to serve as a global summary estimation of the veteran’s functioning excluding medical problems. The DSM-IV states: “ Axis V is for reporting the clinician’s judgment of the individual’s overall level of functioning...The reporting of overall functioning on Axis V is done using the Global Assessment of Functioning (GAF) Scale. The GAF Scale is to be rated with respect only to psychological, social, and occupational functioning. Do not include impairment in functioning due to physical (or environmental) limitations. (p. 30).

The actual GAF rating is the lowest level of either symptom severity or functioning, and this is based on the clinician’s opinion, formed from the available clinical data and history. As the fifth axis in the DSM profile, it represents the severity of Axis I (Clinical Disorders) and Axis II (Personality Disorders) or Axis IV (Psychosocial and Environmental Factors). The GAF Scale, ranging from 0 - 100, and descriptors of levels of symptoms and functioning for each 10- point, decile band (e.g., 81-90, 91-100) are listed in the DSM-IV (p. 32), although “0”, which equals insufficient information, is not an allowed option for rating veterans according to VHA Directive # 97-059. Very little instruction is included in the DSM-IV for how to assign ratings using the scale, and herein lies one of the fundamental problem with assigning GAFs in PTSD cases. As a score based primarily on the rater’s impressions and synthesis of data, solid reliability and validity ultimately determines how useful the GAF scores ultimately can be. Without clear definitions of symptom severity and functional severity —- as they relate to PTSD, and without more detailed instructions for using the GAF scale itself, the clinician is left to decide what to rate and how to do it using personal standards. If the main goal of assigning a GAF score was simply for the individual clinician to have a global rating that they would use personally, then applying their individual interpretation of the scale definitions and the rating process would have limited impact outside of their practice or caseload. However, in the context of Compensation and Pension determinations, consistency and accuracy in ratings needs to be based on a set of standards that are common to all who determine the GAF score and to those who subsequently interpret them when determining benefits.

While no information on the reliability and validity of the GAF is included in the DSM-IV, these psychometric features of the Global Assessment Scale (GAS) were formally examined and published by the GAS authors (Enidcott, Spitzer, Fleiss & Cohen,1976). The GAF and the GAS are almost identical to each other in content, with the exception of some re-arrangement of rating descriptions and examples for the categories. Across five GAS standardization studies reported, the intraclass correlation of the GAS ranged from .61 -.91 with a standard error of measurement of between 5 and 8 points, meaning that the actual GAF score would normally be expected to fall within a 5 to 8 point range around the score. Given the similarities of the GAS and the GAF, the GAS psychometric properties may be true for the GAF as well. Regarding validity, GAS ratings, as measures of overall severity, examined at admission and 6-months later showed more sensitivity to change than single symptoms measures. Correlations of GAS ratings and independent measures of Symptom Criteria were the highest for items representing psychosis and overt behavioral disorganization and low for affect and anxiety-related criteria.

1. GAF Reliability.

Reliability is necessary for GAF scores to be meaningful in the C&P determination process. Reliability in this context is consistency in assigning GAF ratings. If an individual clinician had high reliability with him or herself, they would apply similar standards to the rating process for all GAFs they assigned, and their GAF ratings would be the same or very similar if they rated the same patients again with the same information. For high inter-rater reliability (agreement between raters), different clinicians would arrive at the same or very similar GAF scores if they rated the same patient, presumably because they used the same definitions and applied the same standards to the rating process (vs. simple chance agreement). To achieve consistency, rating scales must use clear definitions for what is to be rated and then specify clear procedures for assigning ratings. This removes or minimizes the need for the rater to make judgments based on their individual perspective. The existing literature shows that in the absence of systematic training with the GAF, reliability is generally poor. Wide variability in GAF ratings is a logical result if each clinician must arrive at their own understanding of what to rate and how to rate it. To deal with this issue, some clinical settings attempt to improve reliability by conducting Consensus Review Groups to reach agreement on assigned GAFs. In the process, local groups of clinicians can increase inter-rater reliability as a result of the group discussion that shapes raters agreement with each other. While this “local standard approach” calibrates the set of raters to each other and results in higher consistency, the GAFs from this setting may not agree with GAFs assigned by other settings for the same patient. Evidence suggests that differences among groups of raters may result in part because clinicians may use different perspectives when they rate symptom severity vs. functional impairment. Also, some raters may average symptom occurrence or functionality over time, while others rate the most recent episode or lowest level of these two components. In disorders like PTSD where symptom severity and functionality can vary, these two approaches will potentially yield very different GAF scores.

2. GAF Accuracy.

Reliability is understandably a main focus because unreliable ratings clearly limit the validity of the GAF. However, complete reliability does not necessarily equal validity; as would be true when all raters agree on a GAF value, but it is the wrong value (i.e., 50 is the consensus GAF, but in reality it should be 30). This might happen when groups of clinicians work toward consensus in their setting, and in the process impose their viewpoints on how to interpret what a GAF score at a given level should be. For example, after years working as a clinician with PTSD veterans, those veterans who have severe symptoms, resulting in multiple personal problems and poor occupational histories, may unintentionally become the norm. By comparison, a veteran who is working steadily, for instance as a long-distance truck driver, may stand out in a positive way as someone who functions in spite of his/her symptoms. In contrast to the symptomatic and unemployed veteran, he is generally functioning better. If this same veteran presented clinically with an episode of increased depression, active suicidal preoccupation, increased irritability, and had initiated a beating of someone who cut him off on the road while he was driving, his GAF scale score for current functioning would place him in the 11-20 band that characterizes someone who is in Some Danger of Hurting Self or Others. In deciding between the two possibilities, symptoms or functioning, symptoms in this case are worse, and the GAF score is based on which of the two is worse. If during the process of reviewing the case information, the clinician applies an “averaging” type of reasoning in the form of: “...well, this was only one episode, and he is working most of the time, and things could be worse (or other veterans are worse off than this), and he shouldn’t be labeled because of this one incident”, then a higher and inaccurate GAF (one that represents a better functional rating) is at risk of being chosen

3. GAF Accuracy and PTSD.

A number of challenges to creating accurate GAFs face the clinician who is tasked with assigning scores for PTSD patients. First, the GAF AXIS V examples for symptoms contained in the DSM-IV do not represent PTSD directly. Also, in cases of chronic PTSD, comorbidity with other diagnoses is common, including substance abuse, major depression, features of other anxiety disorders like panic and OCD, and personality disorders. To assess symptom severity in the context of comorbidity, the clinician must somehow weigh the combined impact of all conditions, but without directions or examples. Second, general descriptors like Mild, Moderate, Serious, etc., that characterize the various 10- point decile bands are open to interpretation and will likely be based on the clinician’s own standards. Third, the clinician must decide what qualifies as a symptom or functional problem to rate. Some symptoms can also be considered functional problems (e.g., PTSD Hypervigilance and Avoidance of people and places). Fourth, making GAF ratings for the 50 - 100 range (moderate symptoms to superior functioning) is less complicated than for the 1- 50 range because the higher ranges reflect low symptomatology

4. Resolution of the GAF Scale.

The GAF scale is organized into ten decile (10-point) bands. The DSM-IV adds a note suggesting that the rater “use intermediate codes when appropriate, e.g., 45, 68, 72)”, but gives only general guidance on exactly how to arrive at these intermediate values. In supplementary GAF material, Dr. Michael First (1995) , the editor of text and criteria for the DSM-IV, suggested using a process where the GAF rater first identifies a decile band that best fits the patient, then decides if the level of symptoms or functioning was nearer to the top of the bandwidth, nearer the middle or nearer the bottom. Depending on this decision by the rater, either a 7, 5 or 2 would be selected to refine and select the final GAF (for example: 47, 45 or 42 within the 41 - 50 decile band). Using this procedure, the finest resolution under the best circumstances is about 3-points, and more practically —- 5 or 10 points because ratings tend to cluster at the middles and ends on the scale (e.g., 45, 50, 55, 60, 65). The difference between raters assigning GAFs for the same patient could vary by 20 points if for example one rater considered the symptoms mild and the other thought they were toward the moderate - severe end of the decile. Thus, using cutoffs that set strict thresholds is unwise and unsupported by both the inherent resolution of the GAF scale and the data showing that raters typically use larger rating intervals.

5. Assigning Separate GAFs by Condition.

Various parts of the foregoing discussion bear on this issue. For a number of reasons, creating the equivalents of PAFs should not be done, although reports from the field indicate that clinicians are being asked to assign PAFs using the GAF scale. First, by name alone, it is clear that the GAF was designed to be a “Global” index of functioning; one that represents in a single value the veteran’s functional status. No published information in the DSM-IV instructs users in a valid method for partitioning the GAF by each comorbid clinical condition, using either separate sets of symptoms for each diagnoses or Social and Occupational / School functioning (although supplementary material suggests that a separate GAF might be created for all symptoms and another for general social/occupational functioning ). While it might appear from the descriptors in DSM-IV (i.e., mild, moderate, serious) that separate ratings by diagnosis could be made (e.g., only for depression symptoms, only for anxiety symptoms, only for substance abuse symptoms), the separate ratings that would result have no validated relationship to each other, and no established means for integrating them into a value that considers the combined effect of having them all concurrently.

Second, if “PAFs” are requested for a disability determination, it is likely that multiple conditions exist comorbidly, and having separate ratings of severity of dysfunction would fit with a process of assigning a percentage of service connection to each particular disorder. In PTSD, depression and substance use frequently coexist and veterans have long-standing problems in occupational, interpersonal, social, familial and psychological domains. Attempting to attribute a portion of the functional problems to depression and another to substance use and another to PTSD, as if they were independent of each other, is beyond the capability of the GAF scale. This is an instance of incompatibility between the capabilities of the GAF scale and the compensation review process. While the logic of separate ratings by disorder may make sense from an adjudication perspective, it is not clinically validated, and “PAFs” assigned in this manner should be seriously questioned for their validity as evidence in the disability determination proceedings.

Some Considerations for Making GAF Ratings

Given the GAF considerations described above, clinicians who assign GAF ratings should: a) attend available trainings, b) study available GAF materials carefully, c) try to assign scores as accurately as possible by adhering to the definitions provided, and d) strive to become consistent with themselves in choosing their GAF ratings.

Outcome data from GAF trainings have shown that raters can have a bias against assigning low GAF scores for PTSD vignettes. This bias, conscious or not, means that all decile bands do not have an equal chance of being selected, and that some will be chosen more than others independently of the case information. For the GAF to be meaningful, it must accurately reflect the Current Severity of the veteran’s symptoms or functioning. For PTSD cases used as part of organized GAF training, it was typically true that the GAF ratings made before training were too high. This reflected various biases and beliefs of the raters regarding what defined a functional problem, and equally important, the rater’s personal perspective on what qualified as a Mild, Moderate, and Serious level of severity. Using the exact same case information, one rater’s standard for Mild Severity might be another rater’s standard for Moderate Severity.

In clinical PTSD contexts, and for those veterans filing valid claims for disability from PTSD attributed to military experiences, symptoms are usually chronic and their overall level of functioning is often poor. GAFs for the majority of these cases will be 50 and under. While many claimants will easily receive a PTSD diagnosis because they meet multiple criteria under DSM-IV Sections B, C, and D, the process of rating PTSD symptom-severity using available information for the GAF scale is difficult. Examples given in the DSM-IV for serious symptoms (41-50 decile band) include: suicidal ideation, severe obsessional situations, and frequent shoplifting. In PTSD contexts, suicidal ideation is often persistent and chronic, and combined with many other symptoms. Regarding these other symptoms, PTSD clinicians would likely agree that regular dissociative flashbacks and high hyperarousal with hit-the-deck startle response is more serious than frequent shoplifting or obsessional rituals. Yet, this is a personal judgment without corroboration in the DSM-IV to serve as a calibration point. Creating ratings of functional impairment using the DSM-IV examples is easier because they represent the impact of symptoms in domains that are common across all diagnoses including PTSD. Applying the DSM-IV examples of social and occupational problems to PTSD patients can be done more easily than for the symptom severity levels.

In making ratings, clinicians should be cognizant of the presence of Violence Toward Self and Others in the veteran’s history. The decile band 11-20 (Some Danger of Hurting Self or Others) gives as examples: a) suicide attempts without clear expectation of death; and b) frequently violent; while the decile band 1-10 ( Persistent Danger of Severely Hurting Self or Others ) lists: a) recurrent violence, and b) serious suicidal act with clear expectation of death. Incidents while driving in traffic are frequently reported as the impetus for aggression towards others, and at times the beating of other drivers; while participating in physical fights is reported as a means of managing anxiety, releasing tension and counteracting depressed mood. In either case, the veteran or others could be hurt. While these events may be episodes of aggression vs. continuous aggression, they are significant features that drop the GAF into the lower decile ranges if they are current when the veteran is assessed. If these features are present clinically, they should not be overlooked or minimized by the clinician when making GAF ratings.

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APPENDIX E: Global Assessment of Functioning
(GAF) Scale
Consider psychological social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations.

100 – 91: Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.

90 – 81: Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).

80 – 71: If symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

70 – 61: Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.

40 – 31: Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).

30 – 21: Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).

The rating of overall psychological functioning on a scale of 0-100 was operationalized by Luborsky in the Health-Sickness Rating Scale (Luborsky L: “Clinicians’ Judgments of Mental Health.” Archives of General Psychiatry 7:407- 417, 1962). Spitzer and colleagues developed a revision of the Health-Sickness Rating Scale called the Global Assessment Scale (GAS) (Endicott J, Spitzer RL. Fleiss JL, Cohen J: “The Global Assessment Scale: A Procedure for Measuring Overall Severity of Psychiatric Disturbance.” Archives of General Psychiatry 33:766-771, 1976). A modified version of the GAS was included in DSM-III-R as the Global Assessment of Functioning (GAF) Scale.

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APPENDIX F: Scoring Rules for Mississippi and PCL-22

Mississippi Scale for Combat-Related PTSD (M-PTSD)

The M-PTSD was originally developed to assess the domain of DSM-III PTSD symptoms and various associated features in combat-exposed Vietnam veterans (Keane et al., 1988), and was subsequently revised to conform to DSM-III-R criteria. The M-PTSD is a 35-item Likert-scaled questionnaire providing a continuous measure of PTSD symptom severity. Internal consistency for the scale was reported to be .94 (Keane et al., 1988), and the test-retest reliability coefficient is .97 (Keane et al., 1988). Factor analytic studies of the M-PTSD have yielded dimensions of intrusive re-experiencing/numbing-avoidance, anger/lability, social alienation, and sleep problems, which correspond to DSM-III-R symptomatic criteria for PTSD (Keane et al, McFall, Smith, Mackay, & Tarver, 1990). Preliminary validation studies using the M-PTSD demonstrated excellent agreement (Kappa = .75) between PTSD diagnoses made by the M-PTSD and the Structured Clinical Interview for DSM-III-R among Vietnam veteran psychiatric patients (Kulka et al., 1988). Sensitivity of the M-PTSD in identifying validated PTSD cases is 93%, and specificity is 88% for various non-PTSD comparison groups (Keane et al., 1988; McFall et al., 1990).

Mean M-PTSD scores among Vietnam veterans have been reported to be 104 among help-seeking patients from a Vet Center and 130 among VA medical center psychiatric patients with PTSD (Keane et al., 1988; McFall et al., 1990). The optimal cutting score for accurately classifying individuals with or without PTSD has varied from study to study, but has ranged between 100 and 107 (Keane et al., 1988; McFall et al., 1990; Watson, 1990)

PTSD Checklist (PCL)

The PCL (Weathers et al., 1993) is a 17-item self-report scale for assessing PTSD symptoms over a variable span of time (one week or one month), appropriate to the context of administration. A version of the PCL is available for assessment of veterans exposed to military traumas (PCL-M) as well as patients exposed to nonmilitary forms of stress (PCLC). The PCL scales are useful as continuous measures of PTSD symptom distress, but can also aid in making a categorical diagnosis of PTSD by summing items across the three DSM-IV symptom clusters of the disorder. Test-retest reliability is .96, and internal consistency is very high (alpha=.93). Convergent validity is supported by high correlations with the Mississippi scale for PTSD (.93), Impact of Event Scale (.90), MMPI PTSD subscale (.77), and the Combat Exposure Scale (.46). The Kappa coefficient for the PCL is reported to be .64. Cross validation studies, on independent samples of Persian Gulf theater veterans, substantiates the aforementioned psychometric properties of the PCL. The PCL can be conveniently administered and scored, and would be appropriate for use as a PTSD screening instrument.

Mr. Jones served in the USMC from August 1966 to August 1969. He volunteered for duty in Vietnam at the age of 18, serving a total of 13 months in that country. He primarily served in the XXXX area from February 1967 through March 1968. His MOS was that of an Amtrak driver, though he actually spent ten months of his duty in a combined action unit with Vietnamese militia. This primarily involved his living in a village with Vietnamese citizens, where he worked in intelligence and also trained and fought with villagers against the Viet Cong.

This individual was exposed to heavy combat for at least ten months of his tour of duty in the combined action unit, engaging the enemy at least twice per week in fire fights, with the exception of December 1967 when he was exposed to daily fire from the enemy. He was involved in a number of combatant roles, including participation in well over 50 combat patrols and ambush operations. In addition, he occasionally participated in river boat patrols where he was fired upon. There was frequent exposure to mines and booby traps, recurrent sniper fire, mortar and rocket attacks and frequent ambushing of his unit by enemy soldiers. He maintains that his village was surrounded by the enemy on at least 30 separate occasions, creating much apprehension that his outfit would be overrun and destroyed. Although his unit primarily fought the Viet Cong, they also engaged NVA soldiers in fire fights. During his tour, Mr. Jones maintains that he was nearly always in danger of being injured or killed, with many near misses. In addition, he witnessed the killing and wounding of American and enemy soldiers on at least 50 separate occasions. Of the 14 Marines in his unit, nine were killed and five were seriously injured. Mr. Jones received four wounds during one particularly severe attack by the enemy, including a gunshot wound to his right bicep, resulting in permanent nerve damage.

This individual is able to describe in considerable detail a number of specific combat traumas he endured. The most severe battle occurred on January 2, 1968, during the Tet Offensive. At that time, Mr. Jones unit was ambushed and destroyed by the villagers with whom they had been living and working for several months. At 1 a.m., his unit was attacked and pinned down in dwellings where they were surrounded by the enemy. Mr. Jones witnessed the slaughter of his own men, but somehow, miraculously, escaped to safety after having been wounded four separate times. He was prepared to kill himself with a hand grenade rather than be captured while he attempted to escape through the bush. He was finally rescued by American forces, being found unconscious in the brush with a hand grenade from which the pin had been pulled clenched to his chest. He recalls another incident when a truck of Army personnel struck a mine and blew up. He was involved for two days in policing the area by picking up various body parts of severely dismembered soldiers. Yet another tragedy occurred when Mr. Jones witnessed his best friend fall to his death from a rope suspended from a helicopter which had suddenly come under fire while engaged in a construction project. Mr. Jones believes that the circumstances contributing to this unfortunate outcome were largely his “fault.”

The veteran claims that his only disciplinary infraction during the military was a “write-up” for having long hair. He maintains that he was nearly abstinent from abuse of substances while in the Service, except for the use of rice wine while in Vietnam. He was discharged honorably with the rank of E-5. Mr. Jones received the Purple Heart for wounds sustained in action and the Navy Commendation Medal with a Combat V for meritorious action while trying to save others during the January 2 assault.

Diagnostic Formulation: Example of Description of PTSD Symptoms

The veteran meets the DSM-IV criteria for Post Traumatic Stress Disorder, chronic, severe. He maintains that he has intrusive, distressing recollections of the aforementioned traumatic experiences on a daily basis. He is awakened from his sleep at least once per week by nightmarish dreams of being overrun and of picking up the bodies of dead soldiers. Although he is oddly attracted to reminders of his wartime experience (displaying his medals at home, watching combat movies), he maintains at the same time that he experiences intense psychological distress when exposed to events that resemble or remind him of his Vietnam experiences. Indeed, he became quite upset during the interview while recounting his combat experiences.

He makes rather extreme efforts to avoid intrusive and painful recollections, to the extent that he gambles compulsively to generate a sense of excitement as well as distract him from inner preoccupation. There is no amnesia for his traumatic events; on the contrary, he remembers nearly every detail quite vividly. There has been a notable and chronic loss of interest in activities and generalized anhedonia since his return from Vietnam, as he has given up most enjoyable pursuits with the exception of working over 60 hours per week, visiting his girlfriend, and gambling. Although formerly quite estranged socially, he appears to be re-establishing meaningful connections with family members and his girlfriend. He endorses the symptom of emotional numbing, maintaining that he is generally emotionally under-reactive and somewhat callous, finding it particularly difficult to express tender and loving feelings toward others. Perhaps most noteworthy, this individual seems to have a sense of a fore-shortened future, feeling as though he “died over there and (is) just a shell.” He seems to be remarkably shortsighted, making few plans for his future other than having vague hopes for marriage to his girlfriend.

There appears to be some modest sleep disturbance, as he awakens briefly once or twice per night. Generally, he claims he is not particularly irritable or angry, having gotten in only six fights since his service days, the last one being over two years ago. However, he maintains that he has intense anger towards the Vietnamese, fearing loss of control of aggressive impulses toward them. He reveals that in 1980 he made a misguided attempt to ram his car into a Vietnamese restaurant. The veteran endorses other symptoms of arousal that seem related to his combat experiences — he is very hypervigilant, easily startled, and physiologically aroused by combat related stimulation such as helicopters. Once of his most bothersome symptoms seem to be guilt about having survived Vietnam while other soldiers died, as well as about acts of brutality towards enemy soldiers and self-perceived failures to rescue friends killed by the enemy.

The patient maintains that many of these symptoms have been present since he was 19, and have been present over 90% of the time during the last five years. They seem to be intensified during the month of January each year, the anniversary of the date when his unit was overrun. Other points of heightened symptom severity occurred in the mid-1970’s when he was depressed and suicidal, and during 1980 when Vietnamese refugees began traveling to the U.S. Although he recognizes the irrational quality of his current hatred towards Vietnamese people, he is quite disdainful of them and fears that he may attack them if provoked.

This patient also meets the criteria for major depression, recurrent, of moderate severity. In particular, he has periods of despondent mood accompanied by anhedonia, a 20-pound weight loss, sleep disturbance, psychomotor retardation, and notable loss of energy and fatigue. He has been self-condemning, feeling quite worthless and inadequate. It appears his current episode of depression has been most severe since about January 1987, to the extent that he lost 20 pounds, withdrew for days at a time on his couch, and, again, ruminated about killing himself with exhaust fumes. There have been approximately 30 such episodes since he was 25, though the current episode is evidently the most severe.

The veteran also meets the criteria for Obsessive Compulsive Disorder, in particular, compulsive gambling. However, it is our opinion that his compulsive gambling is closely linked with his PTSD symptoms, in that they represent deliberate attempts to ward off intrusive memories of a painful nature.

The veteran appears to suffer primarily from symptoms of PTSD, with Major Depression and Compulsive Disorders secondary. It appears that PTSD symptoms of intrusive re-experiencing are most predominant, whereas numbing and avoidant defensive symptoms are present to a lesser degree. Distressing degrees of guilt as well as symptoms of autonomic arousal are also quite noteworthy. With respect to the latter, it should be mentioned that Mr. Jones participated in a research investigation where assessments of his physiological reactivity to combat films were made. He demonstrated observable increases in heart rate and blood pressure, as well as heightened epinephrine response to combat films. Although data from this procedure are in no way a conclusive means of diagnosing PTSD, there is research support demonstrating that such response patterns distinguish veterans with PTSD from non-PTSD psychiatric patients.

CASE II: PTSD Diagnosis

Military History: Example of Trauma History

The veteran, Mr. Smith, enlisted in the Marine Corps, serving from 1965-1977 as an infantry officer. He obtained the rank of First Lieutenant while serving in Vietnam, and was ultimately discharged as a Captain under honorable conditions. Mr. Smith eagerly volunteered for duty in Vietnam, serving 12 months aboard an aircraft carrier off the coast of Vietnam (June 1969 to June 1970), and another eight months as an infantry officer in Vietnam from September 1970 to April 1971. He was 23 years of age when he was sent to Vietnam.

As a platoon commander, Mr. Smith reports he was exposed to “heavy combat,” staging over 100 patrols and ambushes, and having frequent contact with the enemy throughout the duration of his duty. He reports that his unit was surrounded by the enemy on two occasions, and that approximately 25% of the men in his unit were either killed in action or wounded. Though he did not directly fire rounds at the enemy, he was in charge of directing attacks against the enemy in his role as a field commander. He maintains that there were at least 50 occasions in which he was in danger of being injured or killed, either from scattered, harassing sniper fire or from more direct confrontations with the enemy. He maintains that he was not directly involved in killing any of the enemy himself, though he directed fire at the enemy, which did kill and wound the enemy. Mr. Smith was wounded on one occasion when a mortar round hit near him, throwing shrapnel into his arms, chest, and legs, and contributing to a permanent condition of tinnitus, which annoys him considerably. Mr. Smith reports at least one episode of hand-to-hand confrontation with the enemy, when he was exploring a tunnel in the dark and came upon four NVA officers whom he dragged from the tunnel with considerable risk to his own life. The veteran is particularly guilty about one occasion where he led his men into an area that was heavily booby-trapped, resulting in the death of one man and the serious wounding of another four men. The veteran becomes very despondent and tearful when describing this event even today, condemning himself for having failed to prevent this outcome, despite the facts of the case, which do not suggest any negligent conduct on his part. The veteran earned a Bronze Star for valor by exposing himself while wounded to “intense hostile fire and directing the activities of his men.” He also obtained the Purple Heart, the Cross of Gallantry, and the Combat Action Ribbon. Throughout his tour in Vietnam, the veteran maintains that he was somewhat overzealous, being enthusiastic about his Vietnam duty and often taking excessive risks by exposing himself to needless danger while assuming responsibilities that he admits would have been better left to other men in his platoon. In addition to combat exposure, the veteran maintains that he witnessed the torture and mutilation of enemy soldiers.

While in Vietnam, Mr. Smith maintains that he was nearly totally abstinent from alcohol, and did not use illicit drugs. His military career came to an abrupt end when he was charged with attempted murder for obtaining a pistol he planned on using to shoot a superior officer who assigned him to a duty station against his liking. He was hospitalized involuntarily at the Bethesda Naval Hospital from January to May 1977 following this incident, and was terminated from the military shortly thereafter to his great disappointment. Apparently, this was a very uncharacteristic behavior for Mr. Smith, who maintains that he otherwise had a spotless military record with no infractions for conduct problems.

Diagnostic Formulation: Description of PTSD Symptoms

The veteran meets the criteria for Post Traumatic Stress Disorder, chronic, severe. He maintains that he has intrusive, unpleasant thoughts regarding his experiences in Vietnam, which occur several times per day on a nearly daily basis. Moreover, his sleep is chronically disturbed, as he awakens nearly every night with troubling dreams and nightmares about the incident in which he is carrying to safety men who had been wounded in a heavily booby-trapped area where he had to lead them. The veteran is easily reminded of his Vietnam experiences by environmental stimulation, which provides him occasion to ruminate about troubling events (his chronic tinnitus resulting from a mortar explosion near his head is a constant reminder of the war). He maintains that alcohol is one of the few means he has to block preoccupation with intrusive imagery as well as to permit him freedom from troubling and disrupted sleep. The veteran has had less frequent, though quite disturbing, flashback phenomena, the most recent incident being the one where he was wandering around the neighborhood armed and wearing combat fatigues. There is a marked evidence of emotional numbing and constriction to ward off powerful feelings, which have been observed to easily overwhelm him. Despite these efforts, the veteran admits his involvement in repeated dangerous stunts to give him “an adrenaline high” that attempts to replicate the excitement and thrill of combat. (For example, the veteran still frequently hunts rattlesnakes in the wilderness without any weapon and wearing only tennis shoes, catching the snakes by hand.) Consistent with a diagnosis of PTSD, the veteran has a long history of fractured and disrupted relationships that have left him feeling quite alienated and unable to tolerate intimacy. One of his most severe symptoms seems to be guilt, particularly about having not done enough to save his men from being wounded/killed during the aforementioned incident. Moreover, he is preoccupied with having survived Vietnam at all, having expected to die, and feeling as though better men than he were killed. Startle response is evident, with the veteran being jumpy and easily aroused by sounds resembling the environment in Vietnam. He is markedly hypervigilant, needing to keep his back to walls and finding it intolerable to allow others to position themselves where he cannot see them. During our observation of him, he rather ritualistically sat in a corner near an open window day after day without changing his position in the group rooms. Psychophysiological assessment conducted in our facility revealed that Mr. Smith showed marked elevations in blood pressure and heart rate while viewing Vietnam combat films, further documenting his autonomic arousability.

The weight of the clinical evidence points to a marked change in functioning for this individual, from his premilitary to postmilitary adjustment. That is, prior to entering the military and prior to his Vietnam combat experience, this individual appeared to be performing at an exceptional level of adjustment in most spheres of psychosocial functioning. However, since his discharge from the military in 1977, his course has been marked by steady deterioration in which he is clearly achieving beneath his potential, and has a history checkered with disrupted occupational functioning, impaired interpersonal relations, subjective unhappiness, and somewhat compulsive involvement in dangerous stunts that reflect poor judgment and court disaster.

Case III: PTSD Diagnosis with Sexual Harassment/Sexual Assault

Example of Pre- Military and Military History

Ms. Jones is a 40 year old, African American woman who served in the Army from 1980 to 1984. Ms. Jones described a fairly chaotic childhood occurring prior to her military service. She was the youngest of five siblings and her older two sisters report being physically and sexually abused by their alcoholic father. Ms. Jones does not recall specifics of her own sexual abuse by her father, but states that she “believes” she was sexually molested by him. Her parents reportedly separated when Ms. Jones was 10 years old and she has had no contact with her father since. Despite her early difficulties at home, Ms. Jones graduated from high school and reported fairly normal relationships with her peers. She did report feeling that she “did not quite fit in with others.” In retrospect, she attributes this to her struggle over her sexual orientation. Ms. Jones experimented with alcohol in high school but denied any alcohol and/or substance abuse history. She enlisted in the Army after completing high school in order to “make a new life for herself and eventually go to college.”

Initially, during her service, Ms. Jones adjusted well to the military and very much enjoyed her service. Although she was unable to be open about her sexual orientation, she was able to develop a number of friendships and reported feeling mostly “at ease” for the first time in her life. She received positive evaluations from her superior officers and considered whether she would remain in the Army to pursue a military career. However, in 1983, Ms. Jones reported that a group of male servicemen began to sexually harass her. They frequently made sexual comments as she walked by, grabbed her buttocks on several occasions, and asked her whether she had ever “had a real man.” Ms. Jones felt uncomfortable and unsafe around these men and avoided walking alone as a result. Despite her efforts at avoiding contact with the servicemen, Ms. Jones reported that she found herself cornered by one of the men (a higher ranking officer). The officer had been drinking, as was apparent due to the smell of his breath. Ms. Jones attempted to leave the room but the officer was blocking the door. He threatened Ms. Jones, stating that she “would need to sleep with him or else he would make sure everyone knew she was gay.” He also told her there was no use trying to leave since his friends would be waiting for her outside. Ms. Jones feared for her life and was terrified that the other men would also rape her. In addition, she feared being discharged from the military. She reported feelings of terror and helplessness at the time of the assault. Immediately following the assault, Ms. Jones returned to her room, feeling numb.

After this assault, the sexual harassment by the other servicemen appeared to escalate. Ms. Jones feared that the officer had told them about the assault and her sexual orientation. She felt unable to tolerate the harassment and reacted tearfully on each occasion. Her response, unfortunately, only provoked further harassment. She became increasingly distressed and isolated from others, living in constant fear of being assaulted and harassed. Ms. Jones did not report her assault or harassment to higher authorities because she feared retaliation from her harassers. Rather than remaining in the service and suffer further harassment, Ms. Jones decided to leave the military in 1984 and was
honorably discharged.

Description of PTSD Symptoms

Ms. Jones meets the criteria for PTSD, chronic, severe. She has intrusive, distressing recollections of the assault and harassment daily, which she described as “very disturbing.” She also reported having repetitive nightmares approximately two to three times per week in which she is being teased, harassed, and surrounded by 5 servicemen. She awakes from her nightmare short of breath and has significant difficulty returning to sleep. In addition, Ms. Jones reported that, several times a week, certain triggers, such as television programs on the military or recruitment advertisements for the military, cause her to have flashbacks of her assault. She also reported having “daydreams” daily, during which she is suddenly taken back to her memory of being harassed. She described that when she comes out of the “dream”, she sometimes forgets where she is and will often ask others what they were saying. This was observed several times during the interview. In addition, upon cues associated with her assault and harassment, Ms. Jones frequently becomes nauseous and at times tearful. In addition, she exhibits muscle tension, shortness of breath, and psychomotor agitation. These physiological indictors were evident throughout the interview when Ms. Jones was describing the assault and harassment as well as her daily recollections of each.

Ms. Jones also exhibits persistent avoidance of trauma-related cues and numbing. Ms. Jones exerts effort daily to avoid thoughts of her adult sexual assault. Despite her considerable distress, she has not discussed this assault and harassment with anyone, including her sisters. Her avoidance was also apparent in the interview. In particular, Ms. Jones seemed quite uncomfortable from the onset of the interview. She had difficulty maintaining eye contact and frequently offered short answers to questions. She also became tearful when asked about her trauma history and acknowledged her discomfort in discussing these events. Her attempts at avoidance also take the form of complete isolation from others, with the exclusion of her two sisters. She avoids being alone with men and has quit jobs when she has had a male supervisor who she feels she “cannot trust.” Ms. Jones also reported a notable decrease in her interest in pleasurable activities since her return from the service. For example, she used to enjoy frequenting sporting events and concerts, but feels uncomfortable doing so due to the large number of people present. She stated that she feels uncomfortable anywhere in which a large number of men congregate. Ms. Jones also cannot remember important aspects of the traumatic incident. For example, she is unclear as to the date of the sexual assault, although she recalls specific details about what she was wearing and details regarding the location of the assault and the smell of her assailant. Ms. Jones also exhibits significant detachment from others. Although as a child Ms. Jones felt she “did not fit in,” she had established a number of strong peer relationships while in the military. However, after her assault, she became increasingly isolative and detached. She cut off ties with her peers and has not been in contact with any of them for years. Ms. Jones does have some continued contact with her sisters but “has no friends.” In addition, Ms. Jones feels incapable of experiencing normal emotions. She reported feeling numb “everyday,” and cannot remember when she last felt happiness and love.

Ms. Jones also reported severe symptoms of increased arousal attributable to her traumatic experiences. She has significant difficulty falling asleep on a daily basis and experiences mid-sleep awakenings several times a week, usually due to the occurrence of a nightmare (described above). She has difficulty returning to sleep and receives an average of only 3-4 hours of sleep a night. Ms. Jones also reported frequent irritability and some outbursts of anger that typically occur on the job. These outbursts have resulted in Ms. Jones being fired and/or disciplined on a number of occasions. In addition, Ms. Jones exhibits and reported significant concentration difficulties. Her inability to remain focused was evident throughout the interview, especially during discussions of traumarelated material. Ms. Jones stated that her difficulty concentrating is a “daily thing” that has resulted in problems at work. Finally, Ms. Jones reported that she pays excessive attention to “where she is and where others are at all times.” She says she is most vigilant when on public transportation, at work with men, or in a crowded place (which she tries to avoid).

In addition to the symptoms described above, Ms. Jones reported that she is depressed. She cries uncontrollably at times and has limited interest in any activities. She feels a sense of hopelessness and worthlessness and experiences chronic suicidal ideation. In addition, after dismissal from her last job two months ago, she reported that she has lost ten pounds. She also described having limited energy for anything and extreme difficulty getting herself motivated to leave the house.

Overall, it is clear that Ms. Jones has demonstrated a significant change in functioning as a result of the harassment and assault she experienced in the military. She is currently presenting with severe impairments in both social and occupational functioning, evidenced by her social isolation and difficulty maintaining employment. Although it is likely that her trust in others (in particular, men) was also significantly impacted by her childhood trauma and chaotic home environment, she had no previous disciplinary problems in school or the service and had established strong relationships with her peers prior to the events described above. Ms. Jones had also proven to be a hard and reliable worker while in the Army and received positive reviews by her supervising officers. Her symptoms of PTSD and depression were also not present prior to the military assault and harassment and the symptoms began immediately following the reported incidents. In addition, her re-experiencing symptoms are central to the military assault and harassment, rather than her possible childhood abuse. The timing and content of the symptoms clearly suggest that they are related

CASE IV: PTSD Diagnosis

Example of Entire Report

ASSESSMENT REPORT

Mr. Xxxxx is a 72-year-old, married, Caucasian male.

PREMILITARY HISTORY

Mr. Xxxxx’s premilitary adjustment was average to good. He was born in Massachusetts. He was the youngest of 18 children. He lived with his parents and siblings, though his older siblings gradually married and moved out of the home. Mr. Xxxxx stated that his family was poor, but they always had food and clothing. His father was a brick worker, and his mother stayed at home to care for the children. Mr. Xxxxx stated that he was close with his parents and siblings. In terms of discipline, he stated that at times he was spanked, but that he would also be punished by having privileges taken away or being given a chore.

Mr. Xxxxx stated that he enjoyed school and interacted well with other children. He achieved grades at approximately a C level. His conduct was good, and he denied repeating grades or any learning difficulties. He played baseball, hockey, and basketball with neighborhood friends, but was not part of a school team.

Mr. Xxxxx reported very limited use of alcohol and no use of drugs prior to the service (“a few sips of alcohol with my parents,” “I drank a beer after high school graduation”).

MILITARY HISTORY

Mr. Xxxxx was drafted into the Army on October 30, 1944, when he was 18 years old. He was initially sent to Germany in March of 1945, by way of France, but spent most of his time in Austria. Mr. Xxxxx was trained as a rifleman, but served in combat as both a rifleman and scout as part of the 44th infantry division. He attained the rank of Corporal. He was honorably discharged in August of 1946.

Mr. Xxxxx’s duty in World War II would be classified as mainly combat. His report on the combat scale indicated that he had moderate to heavy exposure to combat.

Mr. Xxxxx experienced numerous combat experiences, too many of which to described in this report. Two particularly traumatic events occurred during his service that continue to distress him.

1) Mr. Xxxxx was sworn in and went through infantry training with a friend. He then served in World War II in the same unit with this friend. Mr. Xxxxx stated that in one particular combat situation his friend jumped on top of an activated German grenade and saved the lives of Mr. Xxxxx and those soldiers around him. Mr. Xxxxx described experiencing tremendous fright, knowing that if his friend did not do that, they all would have died. Shortly after, he also experienced significant guilt because of his friend’s death. He described, “I wanted to jump in the line of fire so I could be with him (in heaven).”

2) Mr. Xxxxx reported that two weeks prior to the event described above, he reported that he was riding in a truck with several other soldiers. A grenade fell out of one of the soldier’s pockets (“I can still hear the click and hissing”). He stated that he and the other men jumped from the truck. Mr. Xxxxx stated that he was very scared for his life. Two men were killed during this incident.

In addition to these stressors mentioned above, Mr. Xxxxx stated that he was also troubled by seeing numerous dead and wounded American soldiers, as well as German civilians, including women, children, and the elderly. Mr. Xxxxx’s score on the Combat Exposure Scale of 32 was indicative of moderate to heavy combat exposure, suggesting that Mr. Xxxxx probably was exposed to a whole series of difficult combat experiences typical of that level of exposure.

POST-MILITARY HISTORY AND CURRENT FUNCTIONING

Mr. Xxxxx returned home to Massachusetts following his service. He described that during the first winter he returned, he carried a gun and “took lots of walks to do some thinking.” Mr. Xxxxx stated, “I wanted so much to forget everything, but it is impossible to forget the bad things.”

Mr. Xxxxx reported that he tried to return to his old job as an apprentice in a shipyard. However, he stated that his job was no longer available, and he instead worked as a machinist. Mr. Xxxxx stated that he liked his job, and often worked overtime. He described, “I plunged myself into it, and worked (overtime) to be a good worker, but it also had the bonus of getting my mind off (the war).” Difficulties with sleeping and frequent nightmares were particularly distressing and affected his work. His nightmares would escalate prior to important meetings at work and made him feel “jittery.”

Mr. Xxxxx reported that his symptoms of PTSD were clearly present immediately when he returned from the war. However, because he was able to distract himself with his work, he was able to function fairly successfully. Mr. Xxxxx’s symptoms later exacerbated when he retired in 1988 and had “more time to think.” He was therefore less able to control his symptoms. Although retired, he initially continued to do consulting until 1993. During this time, he reported that he did a fair amount of traveling. He stated that long plane trips gave him time to think about World War II, and his symptoms of PTSD worsened. When Mr. Xxxxx stopped this consulting, he reported that his symptoms became even worse. He stated that whereas previously he could distract himself from his memories through work, he no longer was able to use this coping mechanism. His ability to work and distract himself is still of concern.

At the outset of the assessment he stated, “I would like to be evaluated in the VA to see if I’m capable of working physically. I feel I can, but I’m not sure if I can do it mentally because I can’t sleep or get (the war) off my mind. The biggest thing I’ve lost is not working since I retired.”

Mr. Xxxxx’s retirement and associated increase in PTSD symptomatology have also caused difficulty with his family relationships. Mr. Xxxxx met his current wife in 1948 and married her in 1950. They had one son who was born in 1954. Mr. Xxxxx described being easily frustrated and irritable with his wife and son. He stated, “I realize I am wrong afterwards, but I can’t help acting like I do.” Mr. Xxxxx reported that he also has one or two close friendships. He stated that he never told his friends about the war and grew distant from them because he was “afraid they would think I was an awful person.” Finally, Mr. Xxxxx stated that his symptoms of PTSD also affected him during his personal time, both before and after his retirement. Specifically, during his personal time, he did not have his work to distract himself and he would be very distressed by intrusive thoughts of the war.

Mr. Xxxxx denied use of alcohol more than occasionally, and never used drugs.

Mr. Xxxxx was alert and oriented X3. He was dressed casually, and sometimes came to sessions unshaven. Mr. Xxxxx’s speech was somewhat pressured, but of normal tone. He was very talkative, though he responded to redirection. Mr. Xxxxx’s thought process was logical and goal directed, though frequently he would tell lengthy stories about his experiences in the war that were marked by circumlocution. He denied ever experiencing hallucinations or delusions. Mr. Xxxxx’s stated moods were anxious and depressed, and his affect was consistent with this report. When talking about things that made him upset or anxious, Mr. Xxxxx would frequently shake his hands and was observed to be distressed. Likewise, when he was discussing his past traumatic experiences, Mr. Xxxxx would often cry. Mr. Xxxxx endorsed having passive thoughts of suicidal ideation (“I just like to go to sleep and have it over”). He denied current suicidal intent or plan.

Interview:

The interview data are consistent with a DSM-IV diagnosis of PTSD. Mr. Xxxxx currently meets the following PTSD diagnostic criteria:

(A) Exposure to a recognizable stressor as noted above by combat history and traumatic events (see above).

(B) Re-experiencing of the trauma:

Mr. Xxxxx reported having daily unwanted memories of his traumatic experiences in World War II. He stated that he tries to keep busy to eliminate these thoughts, although this is more difficult to do when he is driving or flying. He described that the thoughts, “go with me wherever I go.”

Mr. Xxxxx stated that 1-2 times per week he has nightmares related to World War II. In particular, he reported having a recurrent nightmare during which 30 troops line up and he marches them to the front. He described, “I’m always the only survivor, and I’m tired and frightened. All the men are the same height and hair as my buddy who was killed. Sometimes I wake up and I can’t breathe.” The dream sequence then repeats, and he goes back to march 30 more troops in clean uniforms into battle. Mr. Xxxxx stated that this sequence can recur 15 times in a night. He stated that when he wakes from his nightmares, it takes him approximately 2 hours to fall back to sleep.

Mr. Xxxxx reported that approximately 1-2 times per month he will experience flashbacks. He stated that they occurred more frequently when he first returned from the war. He described, “I would re-live it. I would yell and scream for everybody to hit the dirt.” More recently, he stated that two weeks ago, he was outside in his yard and heard noises in the bushes and believed someone was sneaking around. He described, “I knew where I was, but for a moment there was the fear that came back. I hear a shot and feel like I’m back as a scout and can’t see my guys because I wandered off too far.”

Mr. Xxxxx stated that several times a week he will become emotionally upset when reminded of the war. This was observed in the interview, during which Mr. Xxxxx cried easily when discussing his memories. He stated, “I never know what’s going to trigger it.” Mr. Xxxxx reported that he will also have a physiological response to reminders. He stated that his heart will race and he will feel like he cannot breathe. At times, this escalates to the level of a panic attack.

(C) Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma):

Mr. Xxxxx stated that he avoids having thoughts and feelings related to his experiences in the war. He will go to great lengths to avoid thinking about the war. For example, he stated that he will try to watch television to distract himself, although this is not always effective. He described, “When I have an avalanche of thinking, unless you chase me with a gun, nothing helps.” Mr. Xxxxx further stated that he avoids watching war movies, as well as going to cemeteries or on nearby roads, because they remind him of death. Moreover, he indicated that at times it is difficult for him to go to the VA (“something grips at me”), although this does not stop him from attending his appointments.

Mr. Xxxxx reported that there are portions of time during his experiences that he cannot remember. In particular, he stated that he is unable to remember the 10 days after his friend died, even with considerable effort. Alternatively, he described, “I clearly remember my buddy dying and the few hours after-that’s the part I wish I couldn’t remember.”

Mr. Xxxxx stated that he has nightly difficulties with sleeping. Mr. Xxxxx described that part of his difficulty with sleeping is related to nightmares and being fearful to go to sleep. He will also lay awake with memories. He reported that it takes him approximately 45 minutes to an hour to fall asleep. He also will have mid-sleep and early morning awakenings. Mr. Xxxxx currently sleeps about 6 hours per night, though he would like to sleep for 8 hours.

Mr. Xxxxx reported difficulties with irritability, and that he will at times become verbally abusive towards his wife and daughter. Mr. Xxxxx stated that his symptoms of irritability increased after he retired. He described, “There was a big difference when I retired and I found myself thinking about the war.”

Mr. Xxxxx described difficulties with concentration much of the time. He stated, “My memories of the war sneak in and it affects everything that I think and do.” He reported that his difficulties with concentration also increased after he retired and “had more time to think about the war.”

Mr. Xxxxx stated that he is always on alert. He reported that he will check his home for safety multiple times. He described, “I’m always on alert for things to happen so I’m ready.” He stated that he is particularly on alert when cars drop off money at a bank or store, and that he has a fear that someone will shoot him in the head while driving. Mr. Xxxxx stated that he also is startled easily and often feels “jumpy.”

Depressive Symptoms:

Mr. Xxxxx reported a number of symptoms of depression. He endorsed feelings of depressed mood and loss of interest in doing activities that he would normally enjoy. Mr. Xxxxx reported that his energy and appetite are poor (“I don’t enjoy food like I used to”). He reported symptoms of guilt, difficulty concentrating, and difficulties sleeping. As mentioned previously, he indicated that at times he has thoughts of wishing he were dead, though denied any current plan to attempt suicide.

It was further evaluated whether these depressive symptoms might be part of a Bipolar Disorder. Mr. Xxxxx denied any manic symptoms consistent with this diagnosis. However, his medical records indicate that current and past treatment providers have felt that Mr. Xxxxx has exhibited manic/hypomanic symptoms at times. Therefore, a diagnosis of Bipolar I or II should be further evaluated longitudinally. It has been our impression that Mr. Xxxxx exhibits hypomanic-like symptoms that may actually be a manifestation of prominent anxiety, as well as a tendency to express himself in a dramatic and emotional fashion.

Current Medications:

Mr. Xxxxx is currently taking Imipramine (25 mg/three times per day) and Lorazepam.

Psychological Treatment History:

Mr. Xxxxx has an extended treatment history with the Brockton VA. He stated that he was seeing Ms Y., MSW, from 1994 to 1999 for both individual therapy and a World War II group medications simultaneously, and associated side effects.

Psychometric Testing:

Mr. Xxxxx completed a MMPI-2. Validity scales of the MMPI suggest that the scales should be interpreted with caution. The profile is indicative of a person who’s abilities to cope with stressors are low. It also is suggestive of a person who is experiencing emotional pain, and has difficulty controlling emotions and behaviors. There is a tendency to admit psychological problems, to be self-critical, and to believe that they have insufficient skills to handle problems.

The interpretive code type that conforms to the high-point scales in the profile was 8-7. This configuration is a variation of the modal 2-8/8-2 profile of other combat veterans with chronic PTSD who are evaluated at the Boston DVAMC. Individuals who obtain this code type on the MMPI-2 are described as frequently worrying, irritable, nervous, agitated, and socially withdrawn. The profile is also suggestive of a person who tends to be guilty and depressed. These individuals have a tendency to feel inferior, be self-critical, and overreact to minor problems. Mr. Xxxxx’s profile was also elevated on scales 6, 3, and 2. This is suggestive of a person who is depressed and has a number of somatic complaints. Further, such individuals may be overly sensitive and concerned that they have not been treated fairly in life.

Mr. Xxxxx scored a 40 on the special PTSD subscale of the MMPI. Patients who have scored 28 and above on this scale have been diagnosed as having PTSD in 82% of the cases examined.

Mr. Xxxxx also completed the Multidimensional Personality Questionnaire. His profile on this measure was suggestive of a person who has few experiences of joy and excitement, and is seldom really happy. The person likes to be alone, and can be distant with others, often preferring to work things out on his/her own. Such individual are nervous, feel vulnerable and sensitive, and are prone to worrying and irritability. Guilt and distress occur at a high frequency even with everyday life conditions. Such individual also have a tendency to react catastrophically to minor mishaps and daily hassles. They may feel mistreated or that others wish to do him/her harm. Finally, such individuals may become readily absorbed in vivid and compelling recollections and imaginings.

Mr. Xxxxx obtained a score of 140 on the Mississippi Scale for Combat-Related PTSD. This score exceeds the cut-off of 107, and is consistent with a diagnosis of PTSD.

Mr. Xxxxx’s score of 44 on the Beck Depression Inventory was indicative of severe levels of depression. His scores of 34 on the Beck Anxiety Inventory also indicated that he has severe levels of anxiety.

In summary, the psychometric findings are consistent with information gathered during the diagnostic and social history interviews for presence and level of symptomatology. The pattern among the psychometric findings supports a diagnosis of PTSD.

Psychophysiological Assessment:

Mr. Xxxxx was evaluated for his appropriateness to have a psychophysiological assessment. This assessment measures the veteran’s cognitive, behavioral, and physiological response to combat scenes as compared to non-combat (control) scenes. The assessment was not deemed necessary at this time because Mr. Xxxxx’s diagnosis of PTSD is clear.

SUMMARY AND RECOMMENDATIONS

In summary, Mr. Xxxxx functioned fairly well prior to the military. However, related to his experiencing several life threatening events during his service, his functioning declined following the military. Mr. Xxxxx met criteria for PTSD immediately when he returned from World War II. His primary coping strategy was to immerse himself in his work as a means of distracting himself from his memories of the war. Consequently, his functioning was still in the range of fair to good following the military. However, when Mr. Xxxxx retired, his primary coping strategy was no longer available. He had more time to think about his past, and his symptoms correspondingly increased. Currently, Mr. Xxxxx is quite symptomatic and is very distressed. This, in turn, has caused discord within his family, and has particularly affected his relationships with his son and wife.

The following recommendations are made:

1) Mr. Xxxxx has been receiving treatment from the VA for a number of years. It is recommended that Mr. Xxxxx seek treatment there for continuity in his care. We have reviewed their treatment plan and it appears to be the best course of action at this time.

2) Mr. Xxxxx reported fair to good functioning for 50 years while working. It is our recommendation that it is extremely important for him to remain active, whether that is in a work environment, in a volunteer position, and/or being active in clubs or other organizations.

3) Diagnostically, there is a question whether or not there is a bipolar process. Data from this evaluation could not support that diagnosis. Though he exhibits hypomanic-like symptoms, it was our impression that these may actually be manifestations of significant anxiety and a tendency towards expressing himself in an exaggerated manner. However, a trial on a mood stabilizer would be valuable to evaluate the effects of this type of medication on his mood.

Xxxxx Xxxxxx is a 59 year-old, remarried, non-service connected, white male referred by Dr. Y. of the V.A. for psychological assessment. Please refer to earlier report for additional background information. The following is a partial evaluation of Mr. Xxxxxx’s psychological status.

Military History

Patient enlisted in the Army during June of 1954. He served approximately 21 months in Germany as a tank driver. He attained the rank of corporal (Sp-3) while in Germany. He was honorably discharged during June of 1957 as an Sp-3.

The patient’s unit was in Germany and Hungary as the Cold War began to intensify. During this time period American troops in Europe were still referred to as the Army of Occupation. Mr. Xxxxxx stated that his company was the only heavy armored American unit in Europe at the time, and that they were on alert for all but one of the months he was stationed there. He was a witness to the Berlin Wall going up, and was fired upon by Russian forces during the Hungarian Revolution. Upon return from Germany the patient was stationed at Fort Carson Colorado where he was assigned to infantry training, a job for which he felt completely unprepared as a tank crewman. The patient’s duty in Europe would be classified as mainly “combat ready”. His report on combat scales indicate that he had light to moderate exposure to combat. Patient reports that none of the men in his unit were killed or wounded while he was stationed in Europe, but that a number of people died while he was stateside, as detailed below. Patient received severe wounds during a training accident and spent several weeks in the hospital.

Military events which patient considered particularly traumatic included:

Europe:

1) The continual tension of being on alert in Europe for 20 months.

2) Witnessing a French tank explode when a crewman dropped a cannon shell which detonated.

3) Being fired upon by Russian and East German troops while under orders not to return fire.

4) Accidentally driving his tank off of a pontoon bridge into the water during the winter. The tank immediately filled with freezing water and gasoline. The patient had frost-bite, and most likely would have died if not for an officer who quickly moved him to the tank’s exhaust to warm him.

5) While driving a tank upon which two squads of troops rode, the patient drove off the road and the tank track caught a piece of concertina wire which whipped across the tank’s top wounding many of the soldiers, including one who lost both legs. The patient takes sole responsibility for this event, even though no disciplinary charges were brought against him.

Fort Carson Colorado:

6) Witnessing a training accident where a recruit dropped a grenade and it detonated in a crowd, killing everyone present. This occurred during a class the patient was responsible for teaching.

7) While setting up an obstacle course with TNT charges, the patient and the company demolitions expert were blown out of a hole when the TNT was accidentally detonated from a remote control board. The patient had noticed that the wires they were to use for detonation were “live”, and he told this to the sergeant who felt no charge when he touched them, and proceeded to wire the TNT. The patient observed people near the control board and thought someone was brushing against the switch, he turned to tell the sergeant this just as the TNT detonated. The sergeant was killed instantly and the patient awoke in the hospital.

Interview: Interview data are consistent with a DSM-III-R diagnosis of PTSD. PTSD diagnostic criteria which the patient meets include:

A) exposure to a recognizable stressor as noted above by military history and traumatic events (see above).

B) re-experiencing of the trauma (need 1):

The patient experiences intrusive and distressing recollections of military events on average twice per week. Intensity is moderate and he reports that he can suppress memories with effort, and that he is very practiced at this. Over the course of the evaluation intrusions have increased in frequency and intensity even though actual discussion of the events has been limited due to the availability of a past Compensation Exam Report. Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic events occurs once or twice per week, and is extremely upsetting to the patient. His inability to control his reactivity to these cues seems to result in an intensity of reaction that is dramatically increased from that he reports to uncued intrusions. The patient reports two severe dissociative episodes related to being blown up with the sergeant. These have both occurred since 1985, but none recently. Mr. Xxxxxx reports that he will wake from a military trauma related nightmare once or twice per week, and that on these occasions his distress is such that he cannot return to sleep for the rest of the night.

C) persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma) (need 3):

The patient reports that he makes daily efforts to avoid thoughts or feelings associated with his trauma. His avoidance is severe and requires considerable effort on his part. He distracts himself as much as possible, drank heavily in the past, worked long hours prior to being disabled, and attempts to suppress thoughts. The patient makes dramatic efforts to avoid activities or situations that arouse recollections of the traumas. Externally cued memories are very upsetting to him and he avoids parades, music concerts, his Vietnam veteran neighbor, his brother who wants to talk about the military generally, obituaries in the newspaper, military-related movies, films containing violence generally, guns, 4th of July celebrations, other veterans, and news programs related to the military. As an example of his avoidance the patient described attending a coming home party for his nephew who participated in Operation Desert Storm. When guests asked about the war the patient felt unable to remain in the house and he left with no explanation. He has not spoken to his sister since that time, and she does not know why he left the party. Since leaving the military, the patient shows markedly diminished interest in significant activities, including hunting, music concerts, social events generally, fishing and camping. The patient reports feelings of detachment or estrangement from others since the early 1970’s when he stopped drinking alcohol. Feelings of detachment and estrangement are severe and almost constant. The patient feels he will not be trusted by others generally, and feels unable to talk to his mother, his siblings, and sometimes not even his wife. Mr. Xxxxxx expressed marked emotional numbing which has been his usual state for many years. Often he feels unable to love anyone. The patient describes a strong sense of foreshortened future. He stated he felt this way all the time, and that he could die “any day now”. He made clear that he was not speaking of suicidal thoughts, but that his future will be cut short at some point. The patient stated that he has felt this way since the mid 1970s.

The patient describes nightly problems with sleep onset, mid, and early awakenings. His sleep loss is profound, and he frequently fears falling asleep. Mr. Xxxxxx states that this has been the case since his discharge from the Army. The patient reports chronic irritability and outbursts of anger on a daily basis. His anger is severe, including verbal or physical aggression. He states that when angered he is prepared for a physical confrontation and has no regard for his own physical safety, in spite of the fact that he has severe physical limitations. The patient reports daily concentration difficulties dating to the 1970s when he would occasionally drive his truck to the wrong stop on his route necessitating unloading his tractor trailer from front to back, the reverse of what one would usually do. He also remarked when asked this question that he had that day driven to the wrong part of town on his way to the hospital, and could not remember where he was supposed to be going.

The patient displays severe symptoms of hypervigilence and feels this way all of the time. He keeps a knife by his bedside, and states he has “ever since the service” (37 years). He describes himself as “paranoid” stating he trusts no one, will not ever live on the first floor of any building due to easy access through windows, can’t stand to have anyone behind him while walking on the street, or in an elevator; will avoid large crowds because he cannot observe everyone. In restaurants he sits with his back to a wall and “watches everyone like a hawk”, and if he cannot get a “safe” seat he will leave the restaurant. He states that he and his wife no longer go to the movie theater together because he insists upon sitting in the last row in the back, which she does not like. Several times per week the patient will hear a noise in his apartment during the night and he will search each room while carrying the knife from his bedside. Mr. Xxxxxx reports a severe startle response once or twice per month including sustained arousal following the initial reaction. Physiologic reactivity upon exposure to trauma related cues occurs once or twice per week and consist of tachycardia, sweating, difficulty catching his breath, and visible trembling.

Mental status:

The patient is a 57 year-old man who appears his stated age. He was casually and neatly dressed and walked with the aid of a cane. His mood and affect were congruent, anxious and dysphoric. There was no evidence of a thought disorder. When discussing traumatic events he expressed a great deal of sadness, guilt, and shame. There was no evidence of suicidal or homicidal thoughts. Although abstraction abilities were not formally tested the patient’s thought processes were concrete and goal directed. Memory and concentration problems were not evident within session, but there was some noticeable forgetfulness between sessions. The patient stated that he suffered a head and back injury in 1985, and that he has been unemployed since that time. He reports that neuropsychological testing revealed some deficits, including reading difficulties (grade level 3 to 4) and poor concentration. The present writer has not reviewed these records. Given the patient’s reading problems only relatively brief psychometric instruments with a direct bearing upon a PTSD diagnosis were administered to him by reading the items and response choices.

Psychometric Testing:

Patient scored a 36 on the special PTSD subscale of the MMPI. Vietnam combat veteran patients who have scored 30 and above on this scale have been diagnosed as having PTSD in 82% of the cases examined.

Patient scored 149 on the Mississippi Scale for Combat-Related PTSD. This score exceeds the 107 cutoff used with Vietnam combat veterans, and is consistent with a diagnosis of PTSD.

SUMMARY

Patient presents with symptoms consistent with a diagnosis of PTSD (DSM-IV Axis I 309.89 Posttraumatic stress disorder). Additionally, he reports some symptoms of depression, and a history of alcohol abuse which clearly was an attempt to self-medicate symptoms of PTSD.

CASE VI: PTSD Diagnosis

The patient reports that within six months of being discharged from the Army, he started to feel depressed, and could not remember a time from the time that he was discharged until present where he actually felt joy in his life. It was within one year of his military injury that he began to experience significant nightmares three to four times per week, of people in uniform chasing him with guns and his not being able to run away or escape them. The nightmares became so intense that he would wake up in the middle of the night with his hands around his wife’s throat or thrash in the bed and hit her or kick her while asleep. When he awoke the next morning, he had no recollection of this. Subsequently, his wife divorced him, though he has had other female bed partners who have been the recipient of similar such violence while he is asleep. These nightmares persist to the present time.

He also experienced recurrent and intrusive distressing recollections of the event including images and perceptions, 20-30 times per week, which he rated as “severe” in interfering with functioning. He would frequently become overwhelmed while in crowds, fearing eminent danger. The patient reports, “I don’t like crowds. I don’t think that anyone in particular is trying to harm me, but it feels that people are following me and trying to do something to me. I just have to run and escape those situations.” Currently, he avoids all crowds, and ultimately all situations that make him feel suspicious and paranoid. He also reports excessive startle when people come up behind him, and when he is awakened by surprise.

Beginning about thirty years ago, the patient has experienced dissociative periods, about 1-2 per month, when he did not know where he was. The last period occurred about one month prior to his last admission. During these times, he could be walking on the street or driving in his care and the next thing that he would remember would be 15-20 minutes later, when he may be sitting on the ground, may be at home, or may be in a strange place. He does not know what has happened during this time lapse.

The patient feels chronically anxious and has felt so the majority of his adult life, with an impending sense of doom, especially when he leaves familiar environment. He also has an inability to recall many aspects of being shot, and has feelings of detachment and estrangement from others. He has had throughout his adult life, a foreshortened sense of future, that he would die at a much younger age.

CASE VII: PTSD Diagnosis

Veteran’s positive symptoms of PTSD since Vietnam include:

1. Persistently re-experiencing the traumatic event in:

• Intrusive thoughts: “especially on rainy cloudy days and when I’m walking at night.”

• Nightmares of Vietnam: “roommates rigged up an alarm system that keeps me from leaving the room, because I was sleep walking when I first got here.”

• Recent flashbacks

• Intense psychological distress with symbolic events

2. Persistent avoidance of associated stimuli, including:

• Trying to avoid thoughts or feelings associated with the trauma. While he is a Domiciliary Resident, he finds that “it’s hard to avoid activities or situations that arouse recollections of the trauma.” For instance, he “sees guys walking around with fatigues, etc.”

• Psychogenic amnesia

• Diminished interest in significant activities

• Feelings of detachment or estrangement from others

• Restricted range of affect: “unable to have loving feelings,” “don’t trust easily,” tends to wonder, “why are you being so nice to me, what do you want to do? I try not to but I can’t help it.”

• Avoidance about thought of the future: “afraid to look into the future, I don’t even go there.”

• Physiologic reactivity upon exposure to events that symbolize the trauma: “heart races.”

• The veteran also experiences depressive symptoms and “survivor guilt.”

CASE VIII: PTSD Diagnosis

The veteran reported that he is moderately to severely depressed. He denied suicidal/homicidal ideation. He said he becomes extremely angry and frustrated at times. The veteran reported that he has distressing dreams and nightmares now about once a week that he remembers, although he wakes up more frequently in the night in cold sweats though unaware of a nightmare. He reported that he has recurrent intrusive recollections of his experiences in Vietnam, not only of the rocket attacks but also of other things that happened, and he said that he feels guilty that he came back when so many of his friends didn’t given that his life is so unproductive. The veteran reported psychological distress and reactivity on exposure to cues, events, and reminders of his experiences in Vietnam. He also reported efforts to avoid thoughts, feelings, activities, and conversations that arouse recollections of his experiences. He keeps to himself, doesn’t like to be around people, stays away from anything on television that might arouse memories. He has become particularly isolative. He describes a recent event in which he went to a Christmas tree lighting ceremony where there were fireworks. This caused feelings of distress, fear, tension, and anxiety and he had to leave the event. He described edginess and hypervigilance, and an exaggerated startle response. He gave various examples of this, including recently being in a friend’s body shop when somebody dropped a metal bar. He said the noise scared him to the point that “he was going to have a heart attack.” The veteran also reported a loss of interest, feelings of detachment, and not feeling close to anyone, restricted affect, a sense of fore-shortened future, sleep disturbances described earlier, irritability, and difficulty concentrating.

Results of psychological testing revealed a score on the Mississippi Scale which fell in the high and significant range. It should be noted that this is exactly the same score that he reported when he was evaluated two years ago. His CES was in the moderate range and a few points lower than it was previously reported in his interview of two years ago. The validity scales on the MMPI-II are moderately elevated but still considered to be interpretable for the purposes of this interview. It is particularly noted that these scores on the validity scales are not as elevated as is often seen in veterans being evaluated for compensation for PTSD. The PK Scale on the MMPI-II is in the significant range. The clinical scales are suggestive of the presence of difficulty concentrating, depression, apathy, feeling isolated and distant from others, sleep disturbances, and interpersonal isolation and withdrawal. Thinking may be confused and there may be feelings of guilt and a sense of personal inadequacy.

In summary, The veteran was interviewed and evaluated to rule in / rule out PTSD associated with a specific stressor event. The veteran did report this as his primary stressor event. He also presented with symptoms of PTSD which he directly related to that event. The veteran does have a history of drug use and dependence but this does not negate the presence of PTSD. Also many of the symptoms of PTSD overlap with depression and the clinical notes throughout his C-file indicate the presence of depression. These are entirely consistent with each other. While his last C & P evaluation did not attribute these symptoms to PTSD, based on this interview, the review of the records as noted in this report, and the consistency of reports noted throughout the records from at least 19xxpresent, and his very early complaint of “nerve problems” in 19xx, it is considered most likely that the veteran is suffering from PTSD and an associated major depression and that this is long-term and chronic.

CASE IX: NO PTSD Diagnosis

Secondary to his exposure to the traumas cited above, the veteran reports occasional distressing recollections, especially when he is exposed to war-related movies and the current Bosnian crisis. He reports waking up in a cold sweat occasionally and yelling “watch out,” according to his wife. He denies memory of his dreams. He reported no incidents of flashbacks. He was quite tearful in discussing the possibilities that he shot an enemy officer during the last stay in the field.

In terms of persistent avoidance and numbing symptoms, the veteran described not wanting to converse about Vietnam, not being able to watch war movies, and an inability to continue hunting activities.

In terms of persistent symptoms of arousal, the veteran described his sleep as “pretty good, “ although he stated that he wakes up 2-3 nights a week in a “cold sweat.” He described no problems with his temper control, and no difficulty concentrating. He described no hyper-vigilant symptoms, but did describe an exaggerated startle response, onset since his return from Vietnam.

Test Results:

The veteran’s responses to psychometric testing appear to be valid. Such individuals are usually described as relatively free of stress, yet willing to admit to minor faults and problems. Such individuals are frequently focused most strongly on the wide variety of physical ailments from which they suffer. It is frequently found that such individuals exhibit somatic problems in response to stress. In terms of emotional distress, such individuals are usually described as very tense and anxious, as well as depressed and alienated from others, and have relatively poor interpersonal relationships as a result. Although the focus of somatic complaints is consistent with the veteran’s presentation, the finding of poor relationships, depression, and unhappiness is inconsistent with his demeanor during the interview as well as his verbal report. The veteran’s completion of the CES yielded a sore suggestive of moderate to heavy combat exposure, which is not consistent with his reported duties in the military. His completion of the Mississippi scale yielded a score below the cutoff suggestive of possible PTSD. His completion of the Keane PTSD Scale also did not reach the level suggestive of possible PTSD. These results are not consistent with the diagnosis of combat-related PTSD.

Summary:

C-file, background, behavioral observations, and test results are not suggestive of a diagnosis of PTSD. The veteran did not report symptoms of a severity suggestive of this disorder, nor did test results suggest possible PTSD. He did not report clear recurrent and intrusive recollections of the traumatic event. He reported dreams that were sufficiently distressing to awaken him, but he has no memory of these dreams. Given his recent [traumatic events], it is conceivable that his dreams are related to these experiences as well as perhaps Vietnam. Finally, the veteran’s current distress appears to be largely an attempt to adjust to his status as unemployed/retired, since 1998, to which he has responded with symptoms of anxiety, not reaching the level of intensity, frequency, or duration indicative of a clinical disorder.

Who were you raised by? Biological / adoptive / foster / step parents
/other_____
Until what age? ____,
Age at enlistment / draft /commission into the military____________
How would you describe your caretakers (type of work, personality):
(mother, father, other) ________________________________________________
____________________________________________________________________
Check any that you feel you experienced during childhood:
❏ Physical abuse / Assault
❏ Sexual abuse / Assault / Molestation
❏ Emotional abuse
❏ Neglect
❏ Witness of Domestic Abuse
❏ Severe stressor
❏ Unwanted sexual advance
❏ Motor Vehicle Accident
❏ Death of family member or close friend
❏ Natural Disaster
❏ Community violence
How many siblings do you have (indicate if step, adoptive)_________________
____________________________________________________________________
What are their names and current ages __________________________________
____________________________________________________________________
____________________________________________________________________
What type of relationship / contact do you currently have with your parents______________________________________________________________
What type of relationship/ contact do you currently have with your
siblings______________________________________________________________
Prior to entering the service, how many years of schooling did you complete?________
Did you earn a high school diploma? ____________________________________
Years of College_______________Degrees?_______________________________
How would you describe yourself during the time prior to entry into the
military_ ____________________________________________________________
How would you describe your pre-military adjustment:
❏ very good ❏ good ❏ average ❏ marginal ❏ poor.

*This Social History Questionnaire may be included in re-exams, for the purpose
of expediting completion of the social and industrial survey.

How would you describe:
School / grades: ❏ very good ❏ good ❏ average ❏ marginal ❏ poor.
Discipline (suspensions from school, police intervention, etc) _______________
General behavior / attitude_____________________________________________
Sports_______________________________________________________________
Social (friends, dating, hobbies) ________________________________________
Did you have any history of trouble as a youth? ___________________________
If so, please describe __________________________________________________
Substance usage prior to military _______________________________________
Any associated problems: ______________________________________________
Pre-military health-related problems (history of hospitalization, significant illness,
injury, including head injury) ______________________________________
What were pre-military stressors:________________________________________
at what ages ______,
Did stressors result in academic problems, hospital, jail, mental symptoms,
treatment, etc) _______________________________________________________
Medications taken regularly prior to military: _____________________________
Psychiatric history prior to military:______________________________________
Family history of psychiatric problems: __________________________________

Education history following active duty___________________________________
Certificate(s) / degree(s) achieved. ______________________________________
Number of jobs held since active duty____________________________________
Type of jobs__________________________________________________________
Longest time employed at one job: ______________________________________
Any problems in jobs (conflict, resulting in firing, etc.) _____________________
____________________________________________________________________
Are you currently: ❏ unemployed ❏ employed.
Current occupation ___________________________________________________
length of time at this job has been __________.

Significant illnesses and injuries: _______________________________________
Hospitalizations:______________________________________________________
Current medications: __________________________________________________
Current disability rating : ______________________________________________
Current subjective mental/emotional complaints: __________________________
____________________________________________________________________
Current psychiatric treatment: __________________________________________
____________________________________________________________________
Number of inpatient hospitalizations for mental /emotional /substance use complaints:______________________________________________________________
The extent of time lost from work over the past 12 month period_____________
____________________________________________________________________
Do you feel that time lost from work is due to your mental / emotional complaints?
_____________________________________________________________

Marital/Relationship History:

Current Marital Status: ❏ Married ❏ Divorced ❏ Separated
Previous marriages: (onset and length of time for each, reason for divorce): ___
____________________________________________________________________
Children’s ages _______________________________________________________
How would you describe your current significant relationship with partner: ____
____________________________________________________________________
How would you describe your current relationship with children:_____________
____________________________________________________________________
What is your current attitude towards social interactions in general: __________
____________________________________________________________________
How do you feel others in your life view you: _____________________________
___________________________________________________________________.
Social support & hobbies: _____________________________________________.